Management of Apixaban (Eliquis) Before Colonoscopy
For patients on apixaban (Eliquis), the medication should be discontinued at least 48 hours prior to colonoscopy when there is a moderate or high risk of bleeding, such as with polypectomy. 1, 2
Risk Stratification for Colonoscopy
Low-Risk Procedures
- Diagnostic colonoscopy with or without biopsies 1
- For low-risk procedures, simply omitting the morning dose of apixaban on the day of the procedure may be sufficient 1
High-Risk Procedures
- Colonoscopy with polypectomy 1
- ERCP with sphincterotomy 1
- EMR/ESD (Endoscopic Mucosal Resection/Endoscopic Submucosal Dissection) 1
- Any procedure with significant risk of bleeding (>1%) 1
Discontinuation Protocol for Apixaban
Standard Protocol (Normal Renal Function)
- Discontinue apixaban at least 48 hours before high-risk colonoscopy procedures 1, 2
- For patients on twice-daily apixaban regimen, this means the last dose should be taken in the morning two days before the procedure 2, 3
Special Considerations
- For patients with impaired renal function (CrCl 30-50 mL/min), consider extending the discontinuation period to 72 hours 1
- For patients with severely impaired renal function, consult with a hematologist 1
- No bridging anticoagulation with heparin is recommended during this interruption period 1, 2
Resumption Protocol After Colonoscopy
- Resume apixaban once adequate hemostasis has been achieved 1, 2
- For low-risk procedures without polypectomy: Resume apixaban as soon as 6 hours after the procedure 4
- For high-risk procedures or after polypectomy: Resume apixaban 24-72 hours after the procedure 1
Important Clinical Considerations
- Studies have shown that discontinuing apixaban for at least 48 hours results in clinically insignificant levels of anticoagulation prior to procedures 3
- Apixaban plasma concentrations of ≤30 ng/mL were achieved in 94% of patients when discontinued for a median of 76 hours 3
- The risk of thromboembolic events during brief interruption of anticoagulation is generally low 3
- Failure to discontinue apixaban for an adequate period before colonoscopy with polypectomy increases the risk of post-polypectomy bleeding 1
Common Pitfalls to Avoid
- Not accounting for renal function when determining discontinuation timing 1
- Unnecessarily prolonged discontinuation, which may increase thrombotic risk 4
- Failing to communicate the plan clearly to patients, leading to confusion about when to stop and restart medication 2
- Resuming anticoagulation too early after polypectomy, which may increase bleeding risk 1
Remember that the FDA label for apixaban specifically states that it "should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding" 2.