When to restart Eliquis (apixaban) after a colonoscopy?

Restarting Eliquis (Apixaban) After Colonoscopy

Eliquis (apixaban) should be restarted up to 48 hours after colonoscopy, depending on the bleeding risk from the procedure and the patient's thrombotic risk. 1

Risk Stratification

Procedure-Related Bleeding Risk

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

  • Diagnostic colonoscopy with or without biopsies
  • Resume Eliquis the same day once adequate hemostasis is achieved

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

  • Colonoscopy with polypectomy
  • Endoscopic mucosal resection (EMR)
  • Endoscopic submucosal dissection (ESD)
  • Resume Eliquis 24-48 hours after the procedure

Patient Thrombotic Risk

• High thrombotic risk:

  • Mechanical mitral valve
  • Prosthetic valve with prior thromboembolism
  • Recent (<3 months) venous thromboembolism
  • Atrial fibrillation with prior stroke or multiple risk factors
  • Resume Eliquis earlier (24 hours post-procedure)

• Low thrombotic risk:

  • Non-valvular atrial fibrillation with lower CHADS₂ score

  • 3 months after venous thromboembolism

  • Can delay Eliquis resumption to 48 hours post-procedure

Specific Timing Recommendations

1. For diagnostic colonoscopy without intervention:

   • Resume Eliquis the same day once adequate hemostasis is achieved 1

2. For colonoscopy with polypectomy or other high-risk intervention:

   • High thrombotic risk patients: Resume Eliquis 24 hours after procedure 1, 2
   • Low thrombotic risk patients: Resume Eliquis 48 hours after procedure 1, 2

3. For large or complex polypectomies (polyps ≥20mm or piecemeal resection):

   • Consider delaying Eliquis resumption for 48-72 hours 2

Important Considerations

• The risk of post-polypectomy bleeding can be as high as 0.8-23% in anticoagulated patients compared to 0.07-1.7% in non-anticoagulated patients 2

• Unlike warfarin, Eliquis reaches therapeutic anticoagulation levels within 2-4 hours after administration, so timing of resumption is critical 3

• No bridging anticoagulation is required when restarting Eliquis 1, 2

• The FDA label for Eliquis states that it "should be restarted after surgical or other procedures as soon as adequate hemostasis has been established" 3

• A 2022 study showed that most patients achieve clinically insignificant levels of apixaban (≤30 ng/mL) within 48 hours of discontinuation 4

Practical Algorithm

1. Assess procedure outcome:

   • Was there complete hemostasis?
   • Were there any complications during the procedure?
   • Size and number of polyps removed?

2. Evaluate patient's thrombotic risk:

   • Review indication for anticoagulation
   • Consider comorbidities and risk factors

3. Determine timing:

   • Uncomplicated diagnostic procedure → Resume same day
   • Standard polypectomy with low thrombotic risk → Resume at 48 hours
   • Standard polypectomy with high thrombotic risk → Resume at 24 hours
   • Complex polypectomy → Consider delaying to 48-72 hours

4. Monitor for complications:

   • Educate patient about signs of bleeding
   • Schedule appropriate follow-up

By following this evidence-based approach to restarting Eliquis after colonoscopy, you can balance the risks of thromboembolism against the risks of post-procedural bleeding.