Can Eliquis (apixaban) be held before undergoing colonoscopy in a patient with a history of recurrent submassive pulmonary embolism (PE) and thrombophilia?

Management of Apixaban Before Colonoscopy in a Patient with Recurrent Submassive PE and Thrombophilia

For a patient with recurrent submassive PE, protein S deficiency, and positive lupus anticoagulant, apixaban should be temporarily discontinued before colonoscopy with appropriate timing, but bridging therapy is not recommended.

Risk Assessment

Thrombotic Risk

This 56-year-old female has multiple high-risk features:

• Recurrent submassive pulmonary embolism
• Thrombophilia with protein S deficiency (activity low at 55)
• Positive lupus anticoagulant (PTT lupus anticoagulant >180)
• History of recurrent PE after previous discontinuation of Eliquis

Bleeding Risk

• Colonoscopy with potential for polypectomy is considered a high-risk procedure for bleeding 1
• The risk increases significantly if therapeutic anticoagulation is maintained during the procedure

Management Algorithm

Pre-Procedure Management

1. Timing of Apixaban Discontinuation:

   • Discontinue apixaban 48 hours before the colonoscopy
   • This represents approximately 4-5 half-lives of the drug, allowing for adequate clearance 2
   • The pharmacodynamic effect of apixaban persists for at least 24 hours after the last dose 2

2. No Bridging Therapy Required:

   • Unlike warfarin, DOACs like apixaban do not require bridging therapy with heparin 1
   • The PAUSE trial demonstrated safety of temporary DOAC cessation without bridging 1
   • Bridging therapy increases bleeding risk without reducing thrombotic events 1

3. Thrombophilia Considerations:

   • Despite protein S deficiency being a higher-risk thrombophilia, current guidelines indicate bridging is typically not required 1
   • The British Society of Gastroenterology specifically notes: "Patients with deficiencies of anti-thrombin, protein C or protein S are at higher risk of thrombosis, but in most of these patients bridging therapy will not be required" 1

Post-Procedure Management

1. Timing of Apixaban Resumption:

   • If no polypectomy or therapeutic intervention: Resume apixaban the same evening after the procedure
   • If polypectomy or other intervention performed: Resume apixaban 24-48 hours after the procedure, depending on the assessed bleeding risk

2. Special Considerations:

   • For large polyps (>1 cm) or multiple polypectomies: Consider delaying resumption to 48 hours
   • If high bleeding risk features are present but thrombotic risk is very concerning: Consider prophylactic clip placement during the procedure to reduce bleeding risk 3

Important Caveats and Pitfalls

1. Consult with Hematology:

   • Given the complex thrombophilia profile (protein S deficiency and lupus anticoagulant), consider hematology consultation before the procedure 1

2. Monitoring for Thrombotic Events:

   • Be vigilant for signs of thrombosis during the perioperative period
   • Patients with a history of venous thromboembolism within 3 months of starting anticoagulation are at particularly high risk if anticoagulation is interrupted 1

3. Procedure Timing:

   • If this is an elective colonoscopy and the patient has had a PE within the last 3 months, consider deferring the procedure if clinically appropriate 1

4. Communication:

   • Ensure clear communication between gastroenterology, primary care, and the patient about the timing of apixaban discontinuation and resumption

By following this approach, you can balance the competing risks of thrombosis and bleeding in this high-risk patient undergoing colonoscopy.