Bleeding Complications Following Paracentesis in Patients Taking Apixaban

Background Both ascites and thrombosis are common complications of liver disease. Abdominal paracentesis to drain ascites has a low reported risk of hemorrhage, but it is unknown how exposure to direct oral anticoagulants (DOACs) such as apixaban increases this risk. Objectives We aim to quantify the rate of major bleeding and identify additional risk factors for bleeding in patients on apixaban undergoing paracentesis. Methods We performed a retrospective cohort study for all patients exposed to apixaban within seven days prior to paracentesis at a single US academic hospital between January 1, 2016, and April 1, 2022. Abstracted data included the presence or absence of hemorrhagic complications, dosing and timing of apixaban administration, and patient comorbidities. Results We identified 365 paracenteses in 91 unique patients. There were 20 (5.5%) reported hemorrhages, nine (2.5%) of which were plausibly related to the procedure. Four (1.1%) patients suffered fatal hemorrhage. Patients taking 10 mg twice daily of apixaban (3/8, 38%), co-prescription of apixaban with more than one additional antiplatelet or anticoagulant (3/16, 19%), apixaban taken within six hours of the procedure (6/37, 16%), and inpatient status (8/158, 5.1%) were associated with bleeding. While internal medicine residents (3/38, 7.9%) had a higher rate of hemorrhage than interventional radiologists (6/289, 2.1%), this difference was negligible when restricted to inpatients (3/38 versus 5/100). Conclusions The rate of bleeding after paracentesis for patients taking apixaban was much higher than historical estimates. Apixaban exposure, especially on high doses, within six hours of the procedure or on additional anticoagulant medications, significantly increases the rate of hemorrhagic complications of paracentesis.