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

Management of Apixaban Before EGD

For a diagnostic EGD with or without biopsy (low-risk procedure), omit only the morning dose of apixaban on the day of the procedure. 1 For therapeutic EGD procedures with high bleeding risk (such as polypectomy, EMR, ESD, variceal therapy, or stricture dilation), stop apixaban 3 days (72 hours) before the procedure. 1

Risk Stratification of EGD Procedures

The critical first step is determining whether your planned EGD is low-risk or high-risk for bleeding: 1

Low-risk procedures:

• Diagnostic EGD with or without mucosal biopsy 1
• Biliary or pancreatic stenting 1
• Device-assisted enteroscopy without polypectomy 1

High-risk procedures:

• Endoscopic polypectomy 1
• ERCP with sphincterotomy 1
• Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) 1
• Endoscopic therapy of varices 1
• Endoscopic dilation of strictures 1
• Percutaneous endoscopic gastrostomy (PEG) placement 1
• EUS with fine needle aspiration 1

Management Protocol for Low-Risk EGD

For diagnostic EGD with biopsies, the most recent BSG/ESGE 2021 guidelines recommend simply omitting the morning dose on the procedure day. 1 This approach is supported by the PAUSE trial, which demonstrated that omitting apixaban for 1 day before low-risk procedures resulted in low rates of major bleeding (1.35%) and arterial thromboembolism (0.16%). 1

Practical approach:

• Patient takes their usual evening dose the night before the procedure 1
• Skip the morning dose on procedure day 1
• Resume apixaban 1 day after the procedure 1

Management Protocol for High-Risk EGD

For therapeutic procedures with significant bleeding risk, apixaban must be stopped for a longer duration to ensure adequate drug clearance: 1

Standard protocol (normal renal function):

• Last dose of apixaban should be taken 3 days (72 hours) before the procedure 1
• This allows approximately 4-5 half-lives for drug elimination 2
• Resume apixaban 2-3 days after the procedure once adequate hemostasis is established 1

The FDA label for apixaban specifies discontinuation at least 48 hours prior to procedures with moderate or high bleeding risk, 2 but the more recent 2021 BSG/ESGE guidelines recommend 3 days based on the PAUSE trial data showing superior safety outcomes. 1

Renal Function Considerations

Apixaban does not require dose adjustment based on renal function for procedural interruption because only 25% is renally cleared. 1 This contrasts with dabigatran, which requires 5 days of interruption when creatinine clearance is 30-50 mL/min. 1

However, if the patient has rapidly deteriorating renal function, consult hematology before proceeding. 1

Bridging Anticoagulation

Do not use bridging anticoagulation with heparin or LMWH during the apixaban interruption period. 1, 2 The rapid offset and onset of apixaban eliminates the need for bridging therapy. 2 Multiple studies demonstrate that bridging increases major hemorrhage rates (2.7% vs 0.5%) without reducing thromboembolism. 1

The only exception would be patients with mechanical heart valves in the mitral position, who should be managed in consultation with cardiology. 1

Common Pitfalls to Avoid

Do not check INR or aPTT to assess apixaban effect - these tests are unreliable for DOACs. 1 If urgent assessment of anticoagulation status is needed, DOAC-calibrated anti-factor Xa levels can be measured. 3, 4

Do not confuse apixaban management with warfarin management - warfarin requires 5 days of interruption and INR monitoring, while apixaban has a much shorter interruption period. 1

Ensure the patient understands "3 days before" means the last dose is 72 hours prior - not stopping 3 days before and taking a dose that morning. 1

Resumption After Procedure

Resume apixaban based on bleeding risk and hemostasis achievement: 1

• Low-risk procedures: Resume 1 day after procedure 1
• High-risk procedures: Resume 2-3 days after procedure once adequate hemostasis confirmed 1

The FDA label states apixaban should be restarted "as soon as adequate hemostasis has been established." 2 In practice, this typically means 48-72 hours for high-risk endoscopic procedures. 1