How long should Eliquis (apixaban) be held before an Esophagogastroduodenoscopy (EGD)?

Management of Apixaban (Eliquis) Before EGD

For high-risk endoscopic procedures like EGD, apixaban should be discontinued 3 days before the procedure in patients with normal renal function. 1

Risk Stratification for EGD Procedures

• EGD procedures are classified based on bleeding risk:
  • Low-risk procedures: Diagnostic EGD with or without biopsies 1
  • High-risk procedures: EGD with interventions (polypectomy, EMR/ESD, therapy of varices, stenting) 1

Discontinuation Protocol for Apixaban

For Low-Risk EGD (Diagnostic Only)

• Simply omit the morning dose of apixaban on the day of the procedure 1
• No need for bridging anticoagulation 1

For High-Risk EGD (With Interventions)

• Normal renal function: Stop apixaban 3 days before the procedure 1
• Impaired renal function (CrCl 30-50 mL/min): Stop apixaban 5 days before the procedure 1
• Severely impaired renal function: Consult with a hematologist for individualized management 1

Special Considerations

• For patients at high thrombotic risk (e.g., mechanical heart valves, recent thrombosis), consultation with a cardiologist or hematologist is recommended to assess the need for bridging therapy 1
• The FDA label for apixaban recommends discontinuation at least 48 hours prior to procedures with moderate or high risk of significant bleeding 2
• Recent research shows that apixaban discontinuation for at least 48 hours results in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 3

Resumption Protocol After EGD

• Resume apixaban once adequate hemostasis has been achieved 2
• For high-risk procedures, typically resume 24-72 hours after the procedure 1, 2
• For low-risk procedures, apixaban can usually be resumed the same day 1

Common Pitfalls to Avoid

• Not accounting for renal function: Apixaban has approximately 27% renal clearance, so impaired renal function requires longer discontinuation periods 1, 4
• Resuming anticoagulation too early: This increases the risk of post-procedural bleeding, especially after interventional procedures 1
• Discontinuing for too long: This increases thrombotic risk, particularly in high-risk patients 1

Monitoring Recommendations

• No routine laboratory monitoring is required before the procedure 1
• Check for signs of bleeding after resuming apixaban 1
• For patients with high thrombotic risk, close monitoring for thrombotic events during the interruption period is recommended 1