When should Eliquis (apixaban) be resumed after a colonoscopy with biopsy?

Resuming Eliquis After Colonoscopy with Biopsy

Eliquis (apixaban) should be resumed 24-48 hours after a colonoscopy with biopsy, once adequate hemostasis has been established. 1, 2

Risk Assessment and Timing Considerations

Procedure Risk Classification

• Colonoscopy with biopsy is classified as a low-risk procedure for bleeding (risk <1%)
• This differs from high-risk procedures like polypectomy or endoscopic mucosal resection 2

Resumption Timeline

1. Standard recommendation: Resume Eliquis 24-48 hours after the procedure
2. FDA label guidance: "Apixaban tablets should be restarted after surgical or other procedures as soon as adequate hemostasis has been established" 1
3. Asian Pacific guidelines: "We recommend resuming DOACs after adequate hemostasis has been achieved" 2
4. European/British guidelines: "If anticoagulant therapy is discontinued, then we recommend this should be resumed up to 48 hours after the procedure depending on the perceived bleeding and thrombotic risks" 2

Decision Algorithm for Resuming Eliquis

Step 1: Assess Hemostasis

• Confirm absence of active bleeding at biopsy site
• Check for clinical signs of bleeding (no hematochezia, stable hemoglobin)

Step 2: Consider Thrombotic Risk

• High thrombotic risk (e.g., recent venous thromboembolism <3 months, mechanical heart valve):

  • Resume at 24 hours if hemostasis is adequate

• Low thrombotic risk:

  • Resume at 48 hours if hemostasis is adequate

Step 3: Consider Renal Function

• Normal renal function (CrCl ≥50 mL/min): Standard resumption timeline
• Moderate to severe renal impairment (CrCl <50 mL/min): Consider extending to 48-72 hours 3

Important Considerations and Caveats

• No bridging anticoagulation is typically required when resuming Eliquis 2, 3
• Monitor for delayed bleeding: Although colonoscopy with biopsy is low-risk, delayed bleeding can still occur, especially in the first week after the procedure
• Dosing: Resume at the same dose the patient was taking before the procedure 1
• Missed doses: If a dose is missed during this interruption period, take it as soon as possible on the same day, but do not double the dose 1

Special Situations

• If there are concerns about complete hemostasis or multiple biopsies were taken, consider extending the resumption time to 48-72 hours
• For patients with both high bleeding and high thrombotic risks, consultation with a hematologist or cardiologist may be warranted to determine the optimal timing for resumption

Remember that while colonoscopy with biopsy is generally considered low-risk, individual patient factors may influence the decision on when to resume anticoagulation. The key principle is to ensure adequate hemostasis before restarting Eliquis to minimize bleeding complications while not delaying anticoagulation unnecessarily in patients at high thrombotic risk.