What are the guidelines for stopping Eliquis (apixaban) in a patient with a history of stroke, without atrial fibrillation (AFib), who is undergoing a colonoscopy?

Management of Apixaban (Eliquis) Interruption for Colonoscopy in Patients with History of Stroke

For patients with a history of stroke without atrial fibrillation who are on apixaban (Eliquis) and need a colonoscopy, apixaban should be discontinued 48 hours before the procedure and resumed as soon as adequate hemostasis has been established after the procedure.

Risk Assessment for Colonoscopy

Colonoscopy with potential polypectomy is considered a high-risk procedure for bleeding according to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1. The bleeding risk must be balanced against the thrombotic risk from temporarily discontinuing anticoagulation.

Procedure Risk Classification:

• High-risk procedures (including colonoscopy with polypectomy):

  • Endoscopic polypectomy
  • Endoscopic mucosal resection (EMR)
  • Endoscopic submucosal dissection (ESD)

• Low-risk procedures:

  • Diagnostic colonoscopy without biopsy
  • Diagnostic colonoscopy with biopsy only

Specific Recommendations for Apixaban Management

Pre-Procedure Management:

• For high-risk procedures (colonoscopy with potential polypectomy):
  • Discontinue apixaban at least 48 hours before the procedure 2
  • No bridging anticoagulation is required 1

Post-Procedure Management:

• Resume apixaban as soon as adequate hemostasis has been established 2
• For most uncomplicated colonoscopies, this is typically the evening of the procedure or the next day
• If polypectomy was performed, consider delaying resumption by 24-48 hours based on the size and number of polyps removed

Special Considerations for Stroke Patients

Patients with a history of stroke without AF represent a special population where the thrombotic risk must be carefully weighed:

1. Thrombotic Risk Assessment:

   • Patients with a history of stroke are at higher risk for recurrent events
   • The absence of AF suggests alternative mechanisms for the initial stroke (e.g., large vessel disease, small vessel disease)

2. Timing Considerations:

   • The risk of recurrent stroke in patients with a history of stroke is elevated when anticoagulation is interrupted 3
   • Minimize the duration of anticoagulation interruption to reduce thrombotic risk

Common Pitfalls and How to Avoid Them

1. Excessive Interruption Duration:

   • Do not stop apixaban earlier than 48 hours before the procedure
   • Longer interruptions unnecessarily increase thrombotic risk

2. Delayed Resumption:

   • Do not delay resumption of anticoagulation beyond what is necessary for hemostasis
   • Prolonged interruption increases thrombotic risk

3. Inappropriate Bridging:

   • Bridging with heparin or LMWH is generally not necessary for apixaban and may increase bleeding risk
   • The short half-life of apixaban (approximately 12 hours) makes bridging unnecessary 4

4. Failure to Communicate with the Endoscopist:

   • Ensure the endoscopist is aware of the patient's anticoagulation status and stroke history
   • This may influence technique selection (e.g., cold snare vs hot snare polypectomy)

Algorithm for Decision-Making

1. Assess procedure bleeding risk:

   • If diagnostic colonoscopy only (no anticipated intervention): Low risk
   • If polypectomy anticipated: High risk

2. For high-risk procedures:

   • Stop apixaban 48 hours before procedure (skip 4 doses)
   • No bridging anticoagulation needed

3. Post-procedure:

   • If no polypectomy or small polyps (<1 cm) removed: Resume apixaban evening of procedure or next morning
   • If large polyps (>1 cm) or multiple polyps removed: Resume apixaban 24-48 hours post-procedure

4. Special situations:

   • For patients at exceptionally high thrombotic risk: Consider performing colonoscopy with continued anticoagulation if only diagnostic or if using cold snare technique for small polyps
   • For patients with very large polyps: Consider delaying resumption up to 72 hours

By following these guidelines, clinicians can minimize both the thrombotic risk associated with temporary discontinuation of apixaban and the bleeding risk associated with colonoscopy and potential polypectomy in patients with a history of stroke.