Should apixaban (Eliquis) be held for an esophagogastroduodenoscopy (EGD)?

From the Guidelines

Eliquis (apixaban) should be held for at least 2 days before a low-risk EGD procedure, and 3 days before a high-risk procedure, as recommended by the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guideline update 1. The decision to hold Eliquis before an EGD procedure depends on several factors, including the patient's renal function, the anticipated bleeding risk of the procedure, and the patient's thromboembolic risk.

• For patients with normal renal function, holding Eliquis for 2 days before a low-risk diagnostic EGD may be sufficient, as demonstrated by the PAUSE trial, which showed low rates of major bleeding or arterial thromboembolism with this approach 1.
• However, for patients with impaired renal function or those undergoing high-risk interventional procedures, a longer duration of Eliquis discontinuation may be necessary, typically 3 days before the procedure.
• It is essential to individualize the decision to hold Eliquis based on the patient's specific situation, taking into account their thromboembolic risk, such as atrial fibrillation or history of venous thromboembolism, versus their bleeding risk.
• After the procedure, Eliquis can typically be resumed 1-2 days later if adequate hemostasis has been achieved, as recommended by the guideline update 1.
• Patients should always consult with both their prescribing physician and gastroenterologist to determine the optimal management strategy for their specific situation, considering the latest evidence and guidelines, such as those from the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 1.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

Eliquis (apixaban) should be held for an EGD, as it is an invasive procedure that carries a risk of bleeding. The exact timing of when to hold Eliquis is not specified for an EGD, but based on the label, it is recommended to discontinue apixaban at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled, and at least 48 hours for procedures with a moderate or high risk of unacceptable or clinically significant bleeding 2.

From the Research

Eliquis and EGD Procedures

• The decision to hold Eliquis for an EGD procedure depends on various factors, including the patient's risk of thromboembolism and the type of procedure being performed 3, 4.
• For low-risk procedures, such as diagnostic EGD with biopsy, it may not be necessary to adjust anticoagulation therapy, including Eliquis 3, 5.
• However, for high-risk procedures, such as those involving polypectomy or endoscopic sphincterotomy, the risk of bleeding may be higher, and alternative anticoagulation strategies may be considered 3, 4.
• Studies have shown that the risk of delayed bleeding in diagnostic EGD with biopsy is low, even in patients taking antithrombotic therapy, including Eliquis 5.
• The safety and efficacy of Eliquis (apixaban) have been evaluated in various studies, including those involving patients with severe renal failure, and have shown advantages over traditional anticoagulation therapies 6, 7.

Anticoagulation Management

• The management of anticoagulation therapy, including Eliquis, during EGD procedures requires careful consideration of the patient's individual risk factors and the type of procedure being performed 3, 4.
• Heparin bridging therapy may not be necessary for most patients on chronic warfarin therapy, except those at high risk of thromboembolism 4.
• A strategy that considers the pharmacokinetic properties of direct oral anticoagulants, such as Eliquis, the bleeding risk of each procedure, and patient renal function can help guide anticoagulation management during EGD procedures 4.
• Further studies are needed to evaluate the safety and efficacy of Eliquis in specific patient populations, such as those with cancer, low or high body weight, or poor renal function 7.