How to Safely Stop Taking Eliquis: A Comprehensive Guide

Eliquis (apixaban) is a commonly prescribed anticoagulant, also known as a blood thinner. It helps prevent blood clots, reducing the risk of stroke and systemic embolism in individuals with atrial fibrillation (AFib), and it’s also used to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). While Eliquis is effective, there might be situations where you and your doctor decide it’s necessary to stop taking it. However, stopping Eliquis abruptly or without proper medical supervision can be dangerous and significantly increase your risk of developing blood clots. This comprehensive guide will provide you with detailed information about how to safely stop taking Eliquis, potential risks, necessary precautions, and alternative options.

Important Disclaimer

This information is intended for educational purposes only and should not be considered medical advice. Never stop taking Eliquis or any other medication without first consulting with your doctor or healthcare provider. Self-treating can be dangerous and can lead to serious health complications. This guide is designed to help you understand the process and potential risks, enabling you to have a more informed discussion with your doctor.

Why Might You Need to Stop Taking Eliquis?

Several reasons might necessitate stopping Eliquis. These include:

• Bleeding Complications: The most common reason to discontinue Eliquis is due to significant bleeding. This could be gastrointestinal bleeding, intracranial hemorrhage (bleeding in the brain), or other severe bleeding events.
• Surgery or Invasive Procedures: Many surgeries and invasive procedures carry a risk of bleeding. Your doctor will likely advise you to temporarily stop Eliquis before the procedure and resume it afterward.
• Drug Interactions: Certain medications can interact negatively with Eliquis, increasing the risk of bleeding or reducing its effectiveness. In some cases, the interacting medication is deemed more important, necessitating a change in anticoagulant therapy or a temporary cessation of Eliquis.
• Kidney or Liver Dysfunction: Eliquis is metabolized by the liver and excreted by the kidneys. If your kidney or liver function significantly declines, your doctor might need to adjust the dosage or discontinue Eliquis altogether.
• Pregnancy or Breastfeeding: Eliquis is generally not recommended during pregnancy or breastfeeding due to potential risks to the fetus or infant.
• Patient Preference: In rare cases, a patient may prefer an alternative treatment option for personal reasons. This should always be discussed thoroughly with a doctor.
• Diagnosis Reversal: If the underlying condition that necessitated Eliquis (e.g., AFib after successful ablation, resolved DVT/PE) is no longer present, your doctor might consider discontinuing the medication after careful evaluation.

The Risks of Stopping Eliquis Abruptly

Stopping Eliquis suddenly can significantly increase your risk of developing blood clots. This is because Eliquis works by inhibiting the formation of clots. When you stop taking it, your body’s natural clotting mechanisms resume, and if the underlying condition that required Eliquis in the first place is still present, the risk of clot formation returns, potentially leading to serious consequences:

• Stroke: For individuals taking Eliquis for atrial fibrillation, stopping the medication abruptly can dramatically increase the risk of stroke. Atrial fibrillation causes an irregular heartbeat, which can lead to blood pooling in the heart and forming clots. These clots can then travel to the brain, causing a stroke.
• Deep Vein Thrombosis (DVT): If you’re taking Eliquis to prevent or treat DVT, stopping it can lead to the recurrence of DVT, which can cause leg pain, swelling, and potentially lead to pulmonary embolism.
• Pulmonary Embolism (PE): PE occurs when a blood clot travels to the lungs, blocking blood flow. It’s a life-threatening condition that can cause shortness of breath, chest pain, and even death. Stopping Eliquis increases the risk of PE in individuals who have previously had or are at risk for this condition.
• Systemic Embolism: Blood clots can travel to other parts of the body, causing damage to various organs and tissues.

How to Safely Stop Taking Eliquis: A Step-by-Step Guide

The key to safely stopping Eliquis is to do so under the direct supervision of your doctor. Do not attempt to stop taking Eliquis on your own.

Here’s a detailed guide to the process:

1. Consult Your Doctor: This is the most crucial step. Schedule an appointment with your doctor to discuss your reasons for wanting to stop taking Eliquis. Be honest and open about your concerns and symptoms. Your doctor will evaluate your overall health, the underlying condition for which you are taking Eliquis, and any potential risks associated with stopping the medication.
2. Medical Evaluation and Risk Assessment: Your doctor will perform a thorough medical evaluation to assess your risk of blood clots if you stop Eliquis. This might involve blood tests, imaging studies (such as ultrasound for DVT or CT scan for PE), and an assessment of your medical history and current medications. They will also evaluate the reason you are taking Eliquis and if that condition still warrants anticoagulation. For example, if you were taking Eliquis for a DVT that was provoked by surgery and you have fully recovered, the risk of recurrence after stopping may be low. However, if you have unprovoked DVT or AFib, the risk of clot formation is significantly higher and requires careful consideration.
3. Develop a Discontinuation Plan: Based on the evaluation, your doctor will develop a personalized discontinuation plan. This plan may involve one of the following approaches:
   • Direct Discontinuation: In some cases, your doctor may recommend stopping Eliquis directly. This is typically only considered if the risk of bleeding significantly outweighs the risk of clotting.
   • Bridging Therapy: Bridging involves using another anticoagulant, such as low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH), to provide anticoagulation during the period when Eliquis is being stopped and before the body’s natural clotting mechanisms fully resume. This is often used before surgery or invasive procedures.
   • Alternative Anticoagulant: Your doctor might switch you to a different anticoagulant that is more suitable for your current situation. This could include warfarin (Coumadin), another direct oral anticoagulant (DOAC) like rivaroxaban (Xarelto), dabigatran (Pradaxa), or edoxaban (Savaysa), or even aspirin in very specific and low-risk cases. The choice of alternative anticoagulant depends on various factors, including your kidney function, liver function, other medications, and personal preferences.
4. Bridging Therapy (If Applicable): If bridging therapy is recommended, your doctor will provide detailed instructions on how to administer the bridging anticoagulant (usually an injection of LMWH) and when to start and stop it in relation to your last dose of Eliquis and the upcoming procedure. It’s crucial to follow these instructions precisely to maintain adequate anticoagulation without increasing the risk of bleeding.
5. Dosage Tapering (Less Common): While less common with Eliquis compared to warfarin, in some specific scenarios your doctor might consider a gradual dose reduction of Eliquis before complete cessation. This is only done under very close monitoring.
6. Monitoring and Follow-up: After stopping Eliquis, your doctor will closely monitor you for any signs or symptoms of blood clots. This might involve regular check-ups, blood tests (such as D-dimer), and imaging studies if necessary. Report any unusual symptoms, such as leg pain or swelling, chest pain, shortness of breath, or sudden weakness, to your doctor immediately.
7. Resumption of Eliquis (If Applicable): If you stopped Eliquis temporarily for surgery or another procedure, your doctor will advise you on when and how to resume taking it. The timing of resumption depends on the type of procedure, the risk of bleeding, and your overall condition.

Detailed Instructions for Different Discontinuation Scenarios

The specific instructions for stopping Eliquis will vary depending on the situation. Here are some common scenarios:

1. Stopping Eliquis Before Surgery or Invasive Procedures

This is a common reason for temporarily stopping Eliquis. The goal is to minimize the risk of bleeding during the procedure.

• Consult Your Surgeon and Cardiologist/Primary Care Physician: It’s essential to inform both your surgeon and your cardiologist or primary care physician about your Eliquis use. They will need to coordinate the discontinuation and resumption of the medication.
• Timing of Discontinuation: Eliquis is typically stopped 48 hours (two days) before surgery for patients with normal kidney function. If you have impaired kidney function, your doctor may recommend stopping it even earlier.
• Bridging Therapy (Possible): Depending on the type of surgery and your risk of blood clots, your doctor may recommend bridging therapy with LMWH or UFH. The decision to bridge is based on individual risk factors. Patients at high risk for thromboembolism, such as those with a history of stroke or recurrent VTE, are more likely to require bridging.
• Resumption of Eliquis After Surgery: The timing of resuming Eliquis after surgery depends on the risk of bleeding. In general, it’s resumed as soon as hemostasis (stopping of bleeding) is achieved, usually within 24-72 hours after surgery. Your doctor will provide specific instructions based on your individual case.

Example Scenario:

John is taking Eliquis for atrial fibrillation and needs to undergo a knee replacement surgery. His doctor advises him to stop Eliquis 48 hours before the surgery. Because John has a moderate risk of stroke, his doctor prescribes LMWH injections to be started 24 hours after his last dose of Eliquis and stopped 24 hours before surgery. After the surgery, once the surgical site is stable and the bleeding risk is low (usually 24-48 hours), John is instructed to restart Eliquis. The LMWH is discontinued once the Eliquis has reached therapeutic levels (usually after 2-3 days).

2. Stopping Eliquis Due to Bleeding

If you experience significant bleeding while taking Eliquis, your doctor may need to stop the medication immediately.

• Seek Immediate Medical Attention: If you experience any signs of serious bleeding, such as blood in your urine or stool, coughing up blood, severe abdominal pain, or unexplained bruising, seek immediate medical attention.
• Management of Bleeding: Your doctor will determine the source of the bleeding and take steps to stop it. This may involve blood transfusions, medications to reverse the effects of Eliquis (Andexxa), or surgery.
• Alternative Anticoagulation: After the bleeding is controlled, your doctor will reassess your need for anticoagulation. If you still require anticoagulation, they may switch you to a different anticoagulant with a lower bleeding risk or adjust the dosage of Eliquis. In some cases, no further anticoagulation may be needed.

3. Stopping Eliquis Due to Drug Interactions

Certain medications can interact with Eliquis, increasing the risk of bleeding or reducing its effectiveness. If you need to take one of these medications, your doctor may need to adjust your Eliquis dosage or switch you to a different anticoagulant.

• Inform Your Doctor About All Medications: It’s crucial to inform your doctor about all medications you are taking, including prescription drugs, over-the-counter medications, and herbal supplements.
• Potential Interactions: Some medications that can interact with Eliquis include:
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs, such as ibuprofen (Advil, Motrin) and naproxen (Aleve), can increase the risk of bleeding when taken with Eliquis.
• Antiplatelet Drugs: Antiplatelet drugs, such as aspirin and clopidogrel (Plavix), can also increase the risk of bleeding.
• Certain Antifungal Medications: Ketoconazole and itraconazole can increase the levels of Eliquis in your blood, increasing the risk of bleeding.
• Certain Antibiotics: Rifampin can decrease the levels of Eliquis in your blood, reducing its effectiveness.
• Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): These antidepressants can increase the risk of bleeding.
• Management of Drug Interactions: Your doctor will assess the risk of the drug interaction and take appropriate measures, such as adjusting the dosage of Eliquis, switching you to a different anticoagulant, or recommending an alternative medication that doesn’t interact with Eliquis.

4. Stopping Eliquis Due to Kidney or Liver Dysfunction

Eliquis is metabolized by the liver and excreted by the kidneys. If your kidney or liver function declines significantly, your doctor might need to adjust the dosage or discontinue Eliquis altogether.

• Regular Monitoring of Kidney and Liver Function: If you have kidney or liver problems, your doctor will regularly monitor your kidney and liver function with blood tests.
• Dosage Adjustment: If your kidney function declines, your doctor may reduce the dosage of Eliquis.
• Alternative Anticoagulation: If your kidney or liver function is severely impaired, your doctor may switch you to a different anticoagulant that is less dependent on kidney or liver function, such as warfarin (Coumadin) or unfractionated heparin (UFH).

5. Stopping Eliquis After Resolution of the Underlying Condition

In some cases, the underlying condition that necessitated Eliquis might resolve, such as successful ablation for AFib or complete resolution of a provoked DVT/PE.

• Evaluation by Your Doctor: Your doctor will carefully evaluate your condition to determine if Eliquis is still necessary. This might involve repeat ECGs for AFib, or ultrasound for DVT.
• Risk Assessment: Your doctor will assess your risk of developing blood clots in the future. If the risk is low, they may consider stopping Eliquis.
• Gradual Discontinuation (Possible): In some cases, your doctor may recommend a gradual dose reduction of Eliquis before complete cessation.
• Close Monitoring: After stopping Eliquis, your doctor will closely monitor you for any signs or symptoms of blood clots.

Alternative Anticoagulants

If you need to stop Eliquis but still require anticoagulation, your doctor may prescribe one of the following alternative anticoagulants:

• Warfarin (Coumadin): Warfarin is a vitamin K antagonist that has been used for decades to prevent blood clots. It requires regular blood tests (INR monitoring) to ensure that the dosage is correct. While effective, the need for frequent monitoring and dietary restrictions can make it less convenient than DOACs like Eliquis.
• Rivaroxaban (Xarelto): Rivaroxaban is another DOAC that works by inhibiting factor Xa, a key component of the clotting cascade. It’s taken once daily.
• Dabigatran (Pradaxa): Dabigatran is a DOAC that works by inhibiting thrombin, another key component of the clotting cascade. It requires twice-daily dosing.
• Edoxaban (Savaysa): Edoxaban is another DOAC that inhibits factor Xa and is taken once daily.
• Low-Molecular-Weight Heparin (LMWH): LMWH, such as enoxaparin (Lovenox) and dalteparin (Fragmin), are injectable anticoagulants that are often used for bridging therapy or in situations where oral anticoagulants are not suitable.
• Unfractionated Heparin (UFH): UFH is another injectable anticoagulant that is used in hospitals for acute anticoagulation.
• Aspirin: In very specific and low-risk cases, aspirin may be considered as an alternative antiplatelet agent. However, it’s generally less effective than anticoagulants for preventing blood clots.

Managing the Transition: Potential Side Effects and What to Watch For

The transition off Eliquis and/or onto another anticoagulant can present potential side effects and require careful monitoring. It’s important to be aware of these and report any concerns to your doctor promptly.

• Increased Risk of Bleeding: Even when carefully managed, any change in anticoagulation carries a risk of bleeding. Watch for signs like easy bruising, nosebleeds, bleeding gums, blood in urine or stool, and unusually heavy menstrual bleeding.
• Thromboembolic Events: As discussed previously, discontinuing anticoagulation increases the risk of blood clots. Watch for symptoms such as leg pain or swelling (DVT), chest pain or shortness of breath (PE), and sudden weakness or difficulty speaking (stroke).
• Side Effects of New Anticoagulant: If you are switched to a new anticoagulant, be aware of its specific side effects. For example, warfarin requires regular blood tests, and some DOACs have specific gastrointestinal side effects.
• Warfarin Transition Challenges: If transitioning to warfarin, understand that it takes several days to reach a therapeutic level. Your doctor will overlap warfarin with Eliquis or another anticoagulant until the INR is within the target range. Dietary changes can significantly impact INR levels.

Lifestyle Considerations During and After Discontinuation

Your lifestyle can play a significant role in managing your risk of blood clots. Here are some important considerations:

• Stay Active: Regular physical activity helps improve circulation and reduce the risk of blood clots.
• Maintain a Healthy Weight: Obesity is a risk factor for blood clots.
• Stay Hydrated: Dehydration can increase the risk of blood clots.
• Avoid Prolonged Immobility: If you need to sit for long periods, take breaks to stretch and walk around.
• Compression Stockings: If you are at risk for DVT, your doctor may recommend wearing compression stockings.
• Healthy Diet: While dietary restrictions are not usually required with Eliquis, if you switch to warfarin, you will need to be careful about your vitamin K intake.
• Smoking Cessation: Smoking increases the risk of blood clots and cardiovascular disease.

When to Seek Immediate Medical Attention

Seek immediate medical attention if you experience any of the following symptoms after stopping Eliquis:

• Sudden shortness of breath
• Chest pain
• Coughing up blood
• Severe abdominal pain
• Blood in your urine or stool
• Sudden weakness or numbness in your face, arm, or leg
• Difficulty speaking
• Sudden vision changes
• Severe headache
• Unexplained bruising or bleeding
• Leg pain or swelling

Conclusion

Stopping Eliquis is a decision that should be made in consultation with your doctor. Abruptly stopping Eliquis can be dangerous and increase your risk of blood clots. Your doctor will evaluate your individual situation and develop a personalized plan to safely discontinue the medication. This may involve bridging therapy, switching to an alternative anticoagulant, or gradually reducing the dosage. Close monitoring is essential after stopping Eliquis to ensure that you do not develop any complications. By working closely with your doctor and following their instructions, you can safely manage your anticoagulation therapy and minimize your risk of blood clots.

Remember to always communicate openly with your healthcare provider about any concerns or symptoms you experience. This article is intended to provide general information and should not be substituted for professional medical advice.