When can Eliquis (apixaban) be started after a Percutaneous Endoscopic Gastrostomy (PEG) tube placement?

When to Restart Eliquis After PEG Tube Placement

Eliquis (apixaban) can be safely restarted 2-3 days after uncomplicated PEG tube placement, depending on the patient's thrombotic risk. For patients at high thrombotic risk, resumption at 48 hours post-procedure is appropriate, while those at lower risk can wait until 72 hours post-procedure 1.

Risk Assessment Framework

Thrombotic Risk Factors (determine timing of restart)

• High risk: Recent venous thromboembolism (<3 months), mechanical heart valve, recent stroke/TIA (<3 months), atrial fibrillation with CHADS2 score ≥4
• Low risk: Atrial fibrillation with CHADS2 score <4, VTE >3 months ago

Bleeding Risk Considerations

• PEG tube placement is classified as a high-risk bleeding procedure according to the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines 1
• The overall risk of hemorrhage for PEG placement is approximately 1.5% 1

Specific Recommendations by Risk Category

High Thrombotic Risk Patients

• Restart Eliquis 48 hours (2 days) after PEG tube placement
• Monitor for signs of bleeding at the PEG site
• Ensure proper PEG site care to minimize bleeding risk

Low Thrombotic Risk Patients

• Restart Eliquis 72 hours (3 days) after PEG tube placement
• This allows more complete healing of the gastrostomy tract

Administration Considerations

• When restarting Eliquis through the PEG tube, ensure proper medication preparation:
  • Eliquis can be crushed and suspended in 50:50 Ora-Plus:water at a concentration of 0.25 mg/mL 2
  • This suspension is stable for up to 7 days at room temperature
  • Flush the PEG tube with water before and after medication administration

Important Clinical Considerations

Pre-Procedure Management

• Eliquis should be discontinued before PEG tube placement:
  • For patients with normal or mildly impaired renal function (CrCl ≥50 mL/min): Last dose 3 days before procedure (skip 4 doses) 1
  • For patients with moderate renal impairment (CrCl 30-50 mL/min): Last dose 4-5 days before procedure (skip 6-8 doses) 1

Post-Procedure Monitoring

• Monitor for signs of bleeding at the PEG site:
  • Visible bleeding around the tube
  • Hematemesis
  • Melena or hematochezia
  • Abdominal pain or distention
  • Hypotension or tachycardia

PEG Site Care

• Proper PEG site care is essential to minimize bleeding risk:
  • Daily cleansing and sterile dressing changes initially 1
  • Ensure the external fixation plate has sufficient free movement (≥5 mm) 1
  • Avoid excessive tension on the tube 1
  • After initial healing (1-2 weeks), the tube should be rotated daily and moved inwards at least once weekly 1

Special Situations

Patients at Very High Bleeding Risk

• Consider delaying Eliquis restart to 4-5 days post-procedure if:
  • Patient has history of GI bleeding
  • Difficult or traumatic PEG placement
  • Coagulopathy from other causes

Patients at Very High Thrombotic Risk

• For patients at extremely high thrombotic risk where earlier anticoagulation is desired:
  • Consider bridging with prophylactic dose low molecular weight heparin starting 24 hours after procedure
  • Then transition to Eliquis at 48-72 hours if no bleeding is observed

Common Pitfalls to Avoid

• Restarting anticoagulation too early (within 24 hours) increases bleeding risk
• Delaying restart beyond 72 hours unnecessarily increases thrombotic risk
• Failing to adjust timing based on renal function
• Not providing proper PEG site care, which can increase bleeding risk
• Overlooking drug interactions that may affect Eliquis levels when restarting

By following these guidelines, clinicians can balance the competing risks of thrombosis and bleeding when restarting Eliquis after PEG tube placement.