What is the recommended protocol for stopping Eliquis (apixaban) before a colonoscopy?

Management of Apixaban (Eliquis) Before Colonoscopy

For patients taking apixaban (Eliquis), discontinue the medication at least 48 hours before a colonoscopy with potential polypectomy, and resume it once adequate hemostasis has been achieved after the procedure. 1, 2

Risk Stratification

Procedure Risk

• Low-risk procedures (bleeding risk <1%):

  • Diagnostic colonoscopy with or without biopsies
  • Management: Omit the morning dose of apixaban on the day of the procedure 1

• High-risk procedures (bleeding risk >1%):

  • Colonoscopy with polypectomy
  • Endoscopic mucosal resection (EMR)
  • Endoscopic submucosal dissection (ESD)
  • Management: Last dose of apixaban should be taken ≥48 hours before the procedure 1, 3

Patient Thrombotic Risk

• Low thrombotic risk: Follow standard discontinuation protocol
• High thrombotic risk (e.g., recent history of pulmonary embolism or DVT):
  • Consider consultation with hematology or cardiology
  • Bridging therapy is generally not required for apixaban 3

Renal Function Considerations

Renal function affects the clearance of apixaban and should guide discontinuation timing:

Renal Function	CrCl (mL/min)	Recommended Last Dose
Normal	≥50	≥48 hours before procedure
Moderate	30-50	≥72 hours before procedure
Severe	<30	Consult hematology [1,3]

Protocol for Apixaban Management

Before Colonoscopy:

1. For low-risk procedures:

   • Omit the morning dose of apixaban on the day of the procedure
   • No bridging anticoagulation required 1

2. For high-risk procedures:

   • Stop apixaban at least 48 hours before the procedure
   • For patients with CrCl 30-50 mL/min, stop 72 hours before
   • For patients with rapidly deteriorating renal function, consult a hematologist 1, 3
   • No bridging anticoagulation is typically required 3

After Colonoscopy:

1. Resume apixaban once adequate hemostasis has been achieved 1, 2
   • For low bleeding risk procedures: typically 24 hours after procedure
   • For high bleeding risk procedures (e.g., large polypectomy): typically 48-72 hours after procedure 3

Important Considerations

• The FDA label for apixaban specifically states it should be discontinued at least 48 hours prior to procedures with moderate or high risk of significant bleeding 2
• The risk of post-polypectomy bleeding is increased in patients on anticoagulants, even when interrupted appropriately 4
• For patients with high thrombotic risk, the decision to discontinue apixaban should balance bleeding versus thrombotic risks 3
• Unlike warfarin, apixaban has a rapid onset and offset of action, so bridging with heparin is generally not necessary 4, 5

Common Pitfalls to Avoid

1. Inadequate discontinuation time: Failing to stop apixaban for sufficient time before high-risk procedures can increase bleeding risk
2. Unnecessary bridging: Unlike warfarin, apixaban generally doesn't require bridging with heparin or LMWH
3. Delayed resumption: Unnecessarily delaying anticoagulant resumption may increase thrombotic risk
4. One-size-fits-all approach: Not accounting for renal function when determining discontinuation timing
5. Failure to communicate: Not discussing the anticoagulation management plan with the patient's cardiologist or primary care provider

By following these guidelines, clinicians can minimize both bleeding complications and thrombotic events when managing patients on apixaban undergoing colonoscopy.