How long should Eliquis (apixaban) be held before an esophagogastroduodenoscopy (EGD) with dilation?

Holding Eliquis (Apixaban) Before EGD with Dilation

For an EGD with dilation, Eliquis (apixaban) should be discontinued at least 48 hours before the procedure as it is considered a high-risk endoscopic procedure for bleeding. 1, 2

Risk Classification and Management Approach

EGD with Dilation: High Bleeding Risk Procedure

Endoscopic dilation of strictures in the upper GI tract is explicitly classified as a high-risk procedure in the BSG/ESGE guidelines 1. This classification is important because it determines the anticoagulation management strategy.

Management Algorithm for Apixaban (Eliquis)

1. Timing of Discontinuation:

   • Hold apixaban for at least 48 hours before the procedure 2
   • For patients with renal impairment (CrCl 30-50 mL/min), extend this to 72 hours 1
   • For patients with rapidly deteriorating renal function, consult a hematologist 1

2. Bridging Anticoagulation:

   • Bridging anticoagulation is not generally required during the 48-hour period after stopping apixaban 2

3. Resumption of Apixaban:

   • Resume apixaban up to 48 hours after the procedure depending on the perceived bleeding and thrombotic risks 1
   • The 2021 updated guidelines recommend resumption up to 2-3 days after the procedure 1

Special Considerations

Thrombotic Risk Assessment

The management may need modification based on the patient's thrombotic risk:

• Low Thrombotic Risk (e.g., atrial fibrillation without valvular disease, >3 months after VTE):

  • Follow standard discontinuation protocol (48 hours)

• High Thrombotic Risk (e.g., mechanical heart valves, recent stents):

  • Consider consultation with a cardiologist or hematologist
  • May require temporary LMWH bridging in specific high-risk scenarios

Post-Procedure Monitoring

• Monitor for signs of bleeding after the procedure
• Be aware that patients on anticoagulants have an increased risk of post-procedure bleeding compared to non-anticoagulated patients 1

Common Pitfalls to Avoid

1. Insufficient Discontinuation Time: Failing to stop apixaban early enough before a high-risk procedure increases bleeding risk

2. Inappropriate Bridging: Unlike warfarin, DOACs like apixaban generally don't require bridging with heparin or LMWH during brief perioperative interruptions

3. Delayed Resumption: Unnecessarily delaying anticoagulant resumption may increase thrombotic risk

4. Ignoring Renal Function: Failing to adjust the discontinuation timeline based on the patient's renal function can lead to excessive anticoagulant effect during the procedure

5. One-Size-Fits-All Approach: Not considering individual patient factors like age, comorbidities, and concomitant medications that might affect bleeding or thrombotic risk

Remember that these recommendations are based on guidelines with varying levels of evidence quality, but the recommendation to hold apixaban for at least 48 hours before high-risk procedures like EGD with dilation is consistent across guidelines and the FDA label.