Resuming Apixaban After Endoscopy
Apixaban should be resumed 2-3 days after endoscopy, depending on your bleeding and thrombotic risks. 1
Risk Assessment Algorithm for Resuming Apixaban
Step 1: Determine the Type of Endoscopic Procedure
Low bleeding risk procedures (diagnostic endoscopy with biopsy, EUS without sampling, diagnostic enteroscopy):
- Resume apixaban within 24 hours if hemostasis is adequate 2
High bleeding risk procedures (polypectomy, ERCP with sphincterotomy, EMR/ESD, stricture dilation, variceal therapy, PEG placement, EUS-FNA):
- Resume apixaban after 2-3 days 1
Step 2: Evaluate Thrombotic Risk
High thrombotic risk (mechanical heart valve, AF with mitral stenosis, recent stroke/TIA, recent VTE within 3 months):
- Resume apixaban at the earlier timeframe (2 days) 1
Low thrombotic risk (AF without high-risk factors, >3 months after VTE):
- Resume apixaban at the later timeframe (3 days) 1
Step 3: Consider Renal Function
- For patients with impaired renal function (CrCl <50 mL/min), consider extending the resumption time by an additional 24 hours 2
Important Considerations
Hemostasis Assessment
- Confirm adequate hemostasis before restarting apixaban 1, 3
- Look for signs of active bleeding: hematemesis, melena, hematochezia, or significant drop in hemoglobin
No Bridging Required
- Unlike warfarin, bridging anticoagulation is not recommended when restarting apixaban 1, 3
- The rapid onset of action of apixaban (peak effect within 3-4 hours) makes bridging unnecessary
Post-Resumption Monitoring
- Monitor for signs of delayed bleeding for 2 weeks after resuming apixaban 1, 4
- Be alert for symptoms such as black stools, dizziness, or abdominal pain
Common Pitfalls to Avoid
Resuming too early: Restarting apixaban too soon (<24 hours) after a high-risk procedure significantly increases bleeding risk 1
Delaying too long: Waiting longer than necessary (>7 days) increases thrombotic risk, particularly in high-risk patients 4, 5
Inappropriate bridging: Using heparin or LMWH bridging with DOACs like apixaban can increase bleeding risk without additional benefit 1
Failing to adjust for renal function: Patients with renal impairment may need longer interruption periods 2
Not considering procedure complexity: More extensive endoscopic interventions may require longer periods before anticoagulant resumption 1
By following this structured approach, you can safely resume apixaban after endoscopy while balancing the risks of thrombosis and bleeding.