Should Eliquis (apixaban) be discontinued before a colonoscopy?

Management of Apixaban (Eliquis) Before Colonoscopy

For patients on apixaban (Eliquis), the medication should be discontinued at least 48 hours prior to colonoscopy if polypectomy or other high-risk endoscopic procedures may be performed. 1

Risk Stratification for Endoscopic Procedures

Low-Risk Procedures

• Diagnostic colonoscopy with biopsies
• Biliary or pancreatic stenting
• Device-assisted enteroscopy without polypectomy

For low-risk procedures, the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines suggest:

• Simply omit the morning dose of apixaban on the day of the procedure 1
• No bridging anticoagulation is required

High-Risk Procedures

• Polypectomy
• Endoscopic mucosal resection (EMR)
• Endoscopic submucosal dissection (ESD)
• Dilation of strictures
• Endoscopic ultrasound with fine needle aspiration

For high-risk procedures such as colonoscopy with potential polypectomy:

• Last dose of apixaban should be taken at least 48 hours before the procedure 1
• For patients with impaired renal function (CrCl 30-50 mL/min), extend this to 72 hours 1
• For patients with severely impaired renal function, hematology consultation is recommended

Special Considerations

Renal Function

Renal function significantly affects the clearance of apixaban:

• Normal renal function (CrCl ≥50 mL/min): Discontinue 48 hours before high-risk procedures
• Moderate renal impairment (CrCl 30-50 mL/min): Discontinue 72 hours before high-risk procedures
• Severe renal impairment (CrCl <30 mL/min): Consult hematology 2

Thrombotic Risk Assessment

The management strategy should consider the patient's thrombotic risk:

• Low thrombotic risk: Follow standard discontinuation protocol
• High thrombotic risk (e.g., recent venous thromboembolism, mechanical heart valve): Consider hematology consultation for potential bridging therapy

Post-Procedure Management

• Resume apixaban up to 48 hours after the procedure depending on the bleeding and thrombotic risks 1
• For most cases, apixaban can be restarted as soon as adequate hemostasis has been established 3
• The FDA label specifically states: "Apixaban tablets should be restarted after surgical or other procedures as soon as adequate hemostasis has been established" 3

Bleeding Risk Considerations

The risk of post-polypectomy bleeding is increased in patients on anticoagulants:

• Overall risk of post-polypectomy bleeding is <0.5% in general population 4
• Risk increases with anticoagulant use, especially with direct oral anticoagulants
• Patients should be advised of this increased bleeding risk 1

Common Pitfalls to Avoid

1. Inadequate discontinuation time: Failing to stop apixaban early enough before high-risk procedures
2. Unnecessary bridging: Unlike warfarin, apixaban generally does not require bridging with heparin due to its shorter half-life 1
3. Delayed resumption: Unnecessarily delaying anticoagulant resumption increases thrombotic risk
4. Failure to adjust timing based on renal function: Patients with impaired renal function need longer discontinuation periods
5. Not communicating with cardiologists: For patients at high thrombotic risk, consultation with cardiology may be necessary

By following these evidence-based guidelines, the risk of both bleeding complications and thromboembolic events can be minimized for patients on apixaban undergoing colonoscopy.