Are there concerns with starting Eliquis (apixaban) after Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Managing Apixaban After ERCP

Apixaban (Eliquis) should be delayed for at least 48 hours after ERCP due to the increased risk of post-procedural bleeding, especially if sphincterotomy was performed during the procedure. 1

Risk Assessment for Post-ERCP Bleeding

ERCP with sphincterotomy is classified as a high-risk endoscopic procedure for bleeding complications:

• Clinically significant hemorrhage occurs in 0.1-2% of sphincterotomies 1
• Risk factors for post-sphincterotomy bleeding include:
  • Bleeding observed during the procedure 1
  • Coagulopathy 1
  • Initiation of anticoagulant therapy within 3 days after the procedure 1
  • Active cholangitis 1
  • Low endoscopist case volume 1

Guidelines for Anticoagulation Management After ERCP

Timing of Apixaban Initiation

• For high-risk endoscopic procedures (including ERCP with sphincterotomy), anticoagulants should be resumed up to 48 hours after the procedure depending on the perceived bleeding and thrombotic risks 1
• The decision to restart anticoagulation should balance the risk of post-procedural bleeding against the risk of thromboembolism 1
• If a sphincterotomy was performed during ERCP, the bleeding risk is higher, warranting a more cautious approach 1

Factors Affecting Timing of Apixaban Initiation

Consider these factors when determining when to start apixaban after ERCP:

1. Procedural factors:

   • Whether sphincterotomy was performed (increases bleeding risk) 1
   • Whether balloon dilation was used instead of cutting (lower bleeding risk) 1
   • Any immediate bleeding observed during the procedure 1

2. Patient factors:

   • Indication for anticoagulation and thrombotic risk 1
   • Renal function (apixaban is ~25% renally cleared) 1, 2
   • Age and comorbidities 1

Special Considerations

Alternatives to Reduce Bleeding Risk

• Endoscopic papillary balloon dilation (EPBD) has been proposed as an alternative to sphincterotomy for biliary stone extraction, with lower incidence of hemorrhage 1
• If EPBD is performed without sphincterotomy, balloon inflation should be maintained ≥1 minute following waist disappearance 1
• For biliary stent placement, sphincterotomy may not be required, potentially reducing bleeding risk 1

Monitoring After Starting Apixaban

• Monitor for signs of bleeding for several days after initiating apixaban 3
• Post-sphincterotomy bleeding can be immediate or delayed (up to several weeks) 1
• Delayed bleeding is more common with anticoagulant use 1

Specific Recommendations Based on Thrombotic Risk

Low Thrombotic Risk Patients

• Delay apixaban for at least 48 hours after ERCP 1
• Consider extending to 72 hours if sphincterotomy was performed and there were any concerns about hemostasis 1

High Thrombotic Risk Patients

• Consider bridging with low molecular weight heparin (LMWH) if immediate anticoagulation is necessary 1
• Start with a lower dose of apixaban if initiating earlier than 48 hours 1
• For patients with mechanical heart valves or recent thrombotic events, consult with cardiology for optimal management 1

Common Pitfalls to Avoid

• Restarting anticoagulation too early after sphincterotomy can increase the risk of delayed bleeding 1
• Failing to account for renal function when dosing apixaban 1, 2
• Not considering the specific ERCP intervention (sphincterotomy vs. balloon dilation vs. stent placement) when assessing bleeding risk 1
• Overlooking drug interactions that may affect apixaban levels 2