What are the guidelines for managing Eliquis (apixaban) in a patient with paroxysmal atrial fibrillation undergoing a screening colonoscopy, should it be stopped or bridged with Lovenox (enoxaparin)?

Management of Apixaban for Patients with Paroxysmal Atrial Fibrillation Undergoing Colonoscopy

For patients with paroxysmal atrial fibrillation on Eliquis (apixaban) undergoing a screening colonoscopy, the medication should be temporarily discontinued for 1-2 days before the procedure without bridging with Lovenox (enoxaparin). 1, 2

Risk Stratification and Timing of Apixaban Interruption

The management approach depends on the bleeding risk of the colonoscopy:

For Standard Screening Colonoscopy (Low-to-Moderate Bleeding Risk):

• Stop apixaban 24 hours before the procedure (skip 2 doses) 1, 2
• Resume apixaban 24 hours after the procedure if adequate hemostasis is achieved 2

For Colonoscopy with High Bleeding Risk (anticipated polypectomy of large polyps):

• Stop apixaban 48 hours before the procedure (skip 4 doses) 1, 2
• Resume apixaban 48-72 hours after the procedure once adequate hemostasis is confirmed 2

Why Bridging with Lovenox is NOT Recommended

The 2022 American College of Chest Physicians guidelines clearly indicate that bridging with LMWH (Lovenox) is unnecessary for patients on DOACs like apixaban 1. This is because:

1. Apixaban has a short half-life (12 hours) with rapid offset and onset of action
2. Bridging therapy increases bleeding risk without reducing thromboembolic events
3. The rapid clearance and predictable pharmacokinetics of apixaban make bridging unnecessary

Important Considerations

Thromboembolic Risk Assessment

For patients with non-valvular atrial fibrillation (the most common type of paroxysmal AF), the short interruption of apixaban therapy poses minimal thromboembolic risk 1. The brief 24-48 hour interruption is well within the safety margin for most patients.

Special High-Risk Situations

In rare cases where patients have extremely high thromboembolic risk (recent stroke/TIA within 3 months, CHADS₂ score ≥5, or AF with mitral stenosis), consultation with cardiology may be warranted, but even in these cases, bridging is generally not recommended 1.

Procedure-Related Considerations

• If the colonoscopy is purely diagnostic with no anticipated interventions, consider the procedure as minimal bleeding risk and apixaban could potentially be continued 1, 3
• If polypectomy is anticipated (common during screening colonoscopy), treat as low-to-moderate bleeding risk procedure 1

Resumption of Anticoagulation

• Resume apixaban at the usual dose once adequate hemostasis is achieved 2
• For standard colonoscopy: resume 24 hours after procedure
• For colonoscopy with polypectomy: resume 48-72 hours after procedure
• No need for a loading dose when restarting 2

Common Pitfalls to Avoid

1. Unnecessary bridging with LMWH: This increases bleeding risk without reducing thromboembolic events 1
2. Prolonged discontinuation: Stopping apixaban for more than 2-3 days unnecessarily increases thromboembolic risk 1
3. Failure to communicate the plan: Ensure clear instructions to the patient about exact timing of last dose before procedure and when to restart
4. Overlooking renal function: For patients with significant renal impairment, the timing may need adjustment (though less critical with apixaban than with dabigatran) 1

By following these evidence-based guidelines, you can safely manage patients with paroxysmal atrial fibrillation on apixaban undergoing colonoscopy while minimizing both bleeding and thromboembolic risks.