How should anticoagulation be managed in a patient with Antiphospholipid Syndrome (APS) on Eliquis (apixaban) undergoing colonoscopy?

Management of Anticoagulation for APS Patient on Apixaban Undergoing Colonoscopy

For a patient with Antiphospholipid Syndrome (APS) on apixaban (Eliquis) undergoing colonoscopy, apixaban should be withheld for 2 days before the procedure and resumed after adequate hemostasis is achieved, with no heparin bridging required.

Risk Assessment for Anticoagulation Management

Thrombotic Risk Factors

• APS diagnosis: Considered a severe thrombophilia 1
• Time since last thrombotic event: Last pulmonary embolism was 2 years ago (moderate-to-low risk category)
• Current anticoagulant: Patient is on apixaban (DOAC)

Procedural Bleeding Risk

• Colonoscopy: Considered a high bleeding risk procedure if polypectomy is anticipated 1

Management Algorithm for Apixaban Before Colonoscopy

1. Pre-procedure management:

   • Withhold apixaban 2 days before the procedure 1
   • No heparin bridging is recommended for patients on DOACs 1

2. Post-procedure management:

   • Resume apixaban after adequate hemostasis is achieved 1
   • Typically can restart within 24-48 hours if no bleeding complications occur

Important Considerations for APS Patients

Apixaban vs. Warfarin in APS

While guidelines generally recommend warfarin over DOACs for APS patients 2, recent evidence suggests:

• Apixaban may have comparable efficacy to vitamin K antagonists in some APS patients 3
• However, caution is warranted as DOACs should be avoided in:
  • Triple-positive APS patients (positive for lupus anticoagulant, anti-cardiolipin, and anti-β2-glycoprotein-I antibodies) 2
  • Patients with history of arterial thrombosis 2

Potential Pitfalls to Avoid

1. Avoid prolonged interruption: Extended periods without anticoagulation increase thrombosis risk in APS patients
2. Avoid heparin bridging with DOACs: Unlike warfarin, bridging is not recommended for DOACs 1
3. Consider patient-specific factors: Higher risk patients (triple-positive antibodies) may require consultation with hematology before temporary DOAC interruption

Post-Procedure Monitoring

• Monitor for signs of bleeding or thrombosis after the procedure
• If polypectomy was performed, consider closer monitoring for delayed bleeding (up to 14 days)
• Resume regular anticoagulation monitoring after procedure

Long-Term Considerations

If the patient has persistently negative antiphospholipid antibodies on follow-up testing, some evidence suggests that discontinuation of anticoagulation might be considered in select low-risk patients 4, though this requires careful evaluation and is not standard practice.