From the Guidelines
An esophagogastroduodenoscopy (EGD) in patients taking apixaban should typically be performed after temporarily discontinuing the medication for 1-2 days before the procedure, depending on the patient's bleeding risk and renal function, as recommended by the most recent guidelines 1.
Key Considerations
- The timing of discontinuing apixaban before an EGD depends on the patient's creatinine clearance (CrCl) and the procedure's bleeding risk.
- For patients with a CrCl > 50 mL/min, apixaban can be discontinued 1 day before a low-risk procedure and 2 days before a high-risk procedure 1.
- In patients with renal impairment (CrCl 30-50 mL/min), apixaban should be held for at least 2 days before a high-risk procedure, and the decision to discontinue apixaban should be individualized based on the patient's thrombotic and bleeding risk factors.
- After the procedure, apixaban can typically be resumed 1-3 days later, depending on the bleeding risk of the intervention performed.
Bleeding Risk Assessment
- The patient's bleeding risk should be assessed based on factors such as the procedure's invasiveness, the presence of bleeding disorders, and the use of other antithrombotic agents.
- The decision to discontinue apixaban should be made in consultation with the patient's healthcare provider, taking into account their individual thrombotic and bleeding risk factors.
Recent Guidelines
- The most recent guidelines from the American College of Chest Physicians recommend a standardized approach to perioperative DOAC management, with interruption of apixaban for 1-2 days before a procedure, depending on the patient's bleeding risk and renal function 1.
- These guidelines are based on evidence from prospective studies, including the PAUSE trial, which demonstrated the safety and efficacy of a standardized approach to perioperative DOAC management 1.
From the Research
Apixaban and EGD Procedures
When considering an esophagogastroduodenoscopy (EGD) for patients taking apixaban, several factors must be taken into account to minimize the risk of bleeding complications.
- The decision to perform an EGD in patients on apixaban should be based on the clinical indication for the procedure and the patient's individual risk factors for bleeding and thromboembolic events 2.
- Studies have shown that apixaban can be safely discontinued for at least 48 hours before an invasive procedure, resulting in a clinically insignificant degree of anticoagulation prior to the procedure 2.
- However, the optimal timing of apixaban discontinuation and resumption after an EGD procedure has not been well established, and clinical management should be individualized based on the patient's risk factors and clinical circumstances.
Bleeding Risks and Apixaban
The risk of bleeding associated with apixaban use is a concern in patients undergoing invasive procedures like EGD.
- A study found that the pooled estimated incidence of any bleeding complications on apixaban was 17.4% (95% confidence interval [CI]: 13.0%-23.0%) in patients with advanced chronic kidney disease (CKD) or end-stage renal disease (ESRD) 3.
- Another study reported a case of gastrointestinal bleeding in a patient with ESRD receiving apixaban, highlighting the need for careful monitoring and dose adjustment in this patient population 4.
Dosing Considerations in Renal Impairment
Patients with renal impairment, particularly those on hemodialysis, require careful consideration of apixaban dosing to avoid excessive drug accumulation and bleeding risks.
- A pharmacokinetic study found that apixaban 2.5 mg twice daily in patients on hemodialysis resulted in drug exposure comparable to the standard dose (5 mg twice daily) in patients with preserved renal function, and may be a reasonable alternative to warfarin for stroke prevention in patients on dialysis 5.
- However, apixaban 5 mg twice daily led to supratherapeutic levels in patients on hemodialysis and should be avoided 5.
Clinical Decision-Making
In summary, the decision to perform an EGD in patients taking apixaban should be based on a careful assessment of the patient's individual risk factors and clinical circumstances.