How long should Eliquis (apixaban) be held prior to a colonoscopy?

Timing of Eliquis (Apixaban) Discontinuation Before Colonoscopy

For patients taking Eliquis (apixaban), discontinue the medication at least 48 hours prior to colonoscopy if polypectomy is anticipated or 24 hours prior for diagnostic colonoscopy with low bleeding risk. 1, 2

Risk Stratification for Colonoscopy

Bleeding Risk Categories

• High bleeding risk procedures:

  • Colonoscopy with polypectomy
  • Endoscopic mucosal resection
  • Colonoscopy with large (>1cm) polyp removal

• Low-to-moderate bleeding risk procedures:

  • Diagnostic colonoscopy
  • Colonoscopy with biopsy only

Specific Timing Guidelines for Eliquis Discontinuation

Based on Procedure Risk

1. High bleeding risk colonoscopy (with polypectomy):

   • Stop Eliquis 48 hours before procedure (skip 4 doses)
   • No bridging anticoagulation required 1

2. Low-to-moderate bleeding risk colonoscopy (diagnostic/biopsy only):

   • Stop Eliquis 24 hours before procedure (skip 2 doses)
   • No bridging anticoagulation required 1, 3

Renal Function Considerations

Adjust timing based on renal function:

• Normal renal function (CrCl ≥50 mL/min):

  • Follow standard recommendations above

• Impaired renal function (CrCl <50 mL/min):

  • Consider extending discontinuation period to 72 hours for high bleeding risk procedures 3

Resumption of Eliquis After Colonoscopy

Based on Procedure Risk

1. Low bleeding risk procedures:

   • Resume Eliquis 24 hours after procedure 1

2. High bleeding risk procedures:

   • Resume Eliquis 48-72 hours after procedure 1
   • Consider delaying resumption if there are concerns about hemostasis

Important Considerations

Thrombotic Risk Assessment

• For patients at high thrombotic risk (recent VTE, mechanical heart valves, high CHADS₂ score):
  • Balance bleeding vs. thrombotic risk
  • Consider shorter interruption periods when possible
  • Consult with cardiology/hematology for complex cases

Practical Points

• Ensure adequate hemostasis is achieved before resuming Eliquis
• No laboratory monitoring is required before procedure if following recommended interruption periods
• The FDA label specifically states that Eliquis should be discontinued at least 48 hours prior to elective procedures with moderate or high risk of bleeding, and 24 hours prior to procedures with low bleeding risk 2

Common Pitfalls to Avoid

1. Unnecessary bridging: Unlike warfarin, Eliquis has a rapid onset and offset of action, making bridging with heparin products unnecessary and potentially increasing bleeding risk 1

2. Inadequate discontinuation time: Failing to stop Eliquis for sufficient time before high-risk procedures can lead to excessive bleeding

3. Delayed resumption: Unnecessarily prolonged discontinuation increases thrombotic risk without providing additional safety benefit

By following these evidence-based guidelines for the perioperative management of Eliquis around colonoscopy, you can minimize both bleeding and thrombotic complications.