Is bridging therapy with Lovenox (enoxaparin) needed for a patient with Antiphospholipid Syndrome (APS) and a history of recurrent pulmonary embolism who will undergo colonoscopy after interrupting Eliquis (apixaban)?

Bridging Therapy for APS Patient with History of Recurrent PE Undergoing Colonoscopy

Bridging therapy with Lovenox (enoxaparin) is recommended for this patient with Antiphospholipid Syndrome (APS) and history of recurrent pulmonary embolism who missed 5 days of Eliquis (apixaban) and will undergo colonoscopy.

Rationale for Recommendation

High Thrombotic Risk Patient

• This patient has two critical high-risk factors:
  • Antiphospholipid Syndrome (APS) - a hypercoagulable state
  • Recent recurrent pulmonary embolism after only 5 days without anticoagulation

Guideline-Based Decision Making

1. APS-Specific Considerations:

   • The American College of Cardiology recommends maintaining continuous anticoagulation without interruption in patients with arterial APS 1
   • Patients with APS have significantly higher thrombotic risk, with DOACs showing higher risk of recurrent arterial thrombosis compared to warfarin 1

2. Procedure-Related Considerations:

   • According to the BSG/ESGE guidelines, apixaban should be discontinued at least 48 hours prior to high-risk endoscopic procedures 2
   • Colonoscopy with potential polypectomy is considered a high-risk procedure for bleeding

3. Bridging Protocol:

   • The FDA label for apixaban states: "Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required" 3
   • However, this general recommendation does not apply to high-risk patients like those with APS and recent thrombosis

Implementation Plan

Pre-Procedure Management

1. Discontinue Eliquis (apixaban):

   • Stop apixaban 48 hours before colonoscopy 2, 3

2. Initiate Lovenox (enoxaparin):

   • Begin enoxaparin when next dose of apixaban would have been taken
   • Recommended dosing: 1 mg/kg twice daily 1
   • For patients with moderate risk, a half-therapeutic dose regimen (1 mg/kg once daily) may be considered 4, 5

3. Pre-Procedure Timing:

   • Administer last dose of enoxaparin at least 24 hours before the procedure
   • For morning procedures: Give last dose the morning of the day before procedure
   • For afternoon procedures: Give last dose the evening before procedure (at half the daily dose)

Post-Procedure Management

1. Resume Lovenox:

   • If no bleeding complications: Resume enoxaparin 24 hours after procedure
   • If high bleeding risk from polypectomy: Delay resumption for 48-72 hours

2. Restart Eliquis:

   • Resume apixaban when adequate hemostasis is established (typically 24-48 hours post-procedure)
   • Continue enoxaparin until apixaban reaches therapeutic effect (approximately 2-3 days of overlap)

Important Considerations

Caution Points

• A case report demonstrated fatal pulmonary embolism in an APS patient who received only low-dose heparin and aspirin for perioperative management 6
• Patients with APS have significantly higher risk of recurrent thrombosis compared to other anticoagulated patients
• The patient's history of recurrent PE after only 5 days without anticoagulation indicates extremely high thrombotic risk

Bleeding Risk

• Bridging therapy increases bleeding risk 2-3 fold 1
• The BSG/ESGE guidelines note increased post-polypectomy hemorrhage with bridging therapy 2
• Balance this against the demonstrated high thrombotic risk in this specific patient

Follow-Up Recommendations

• Monitor for signs of bleeding for 2 weeks post-procedure
• Ensure consistent anticoagulation with apixaban once resumed
• Consider long-term uninterrupted anticoagulation strategy for future procedures if clinically appropriate

This approach prioritizes prevention of potentially fatal recurrent pulmonary embolism while managing the increased bleeding risk associated with bridging therapy in this high-risk APS patient.