Apixaban Management for Colonoscopy
For colonoscopy with polypectomy or other high-risk interventions, hold Eliquis (apixaban) for 48 hours (2 days) before the procedure in patients with normal renal function. 1, 2, 3
Pre-Procedure Management Based on Bleeding Risk
High-Risk Procedures (Colonoscopy with Polypectomy, EMR/ESD)
- Stop apixaban 48 hours (2 days) before the procedure if creatinine clearance ≥50 mL/min 1, 2, 3
- Extend to 72 hours (3 days) if creatinine clearance 30-50 mL/min to account for reduced renal elimination 1, 2
- This timing allows approximately 4 half-lives to elapse, resulting in minimal (≤6%) residual anticoagulant effect at the time of procedure 1
- The FDA label specifically recommends discontinuing apixaban at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding 3
Low-Risk Procedures (Diagnostic Colonoscopy with Biopsies Only)
- Simply omit the morning dose on the day of the procedure 1, 2
- This approach allows biopsies to be taken at trough anticoagulant levels, minimizing bleeding risk while maintaining some anticoagulant coverage 1
- The FDA label supports discontinuing at least 24 hours prior to procedures with low bleeding risk 3
Post-Procedure Resumption
After High-Risk Procedures
- Resume apixaban 24-72 hours after the procedure once adequate hemostasis is achieved 1, 2
- For patients at high thrombotic risk, consider starting with a reduced dose (2.5 mg twice daily) for the first 2-3 days, then increase to full dose (5 mg twice daily) 1
- The 2022 CHEST guidelines recommend resuming DOACs at least 24 hours after high-bleed-risk procedures 1
After Low-Risk Procedures
- Resume apixaban the same day or next day after the procedure 2, 4
- Full-dose resumption is appropriate for low-risk procedures 1
Critical Considerations
Renal Function Assessment
- Always check renal function before determining the hold period 1, 2
- Apixaban has 25% renal clearance, and impaired renal function prolongs drug half-life 1
- For CrCl <30 mL/min, consult hematology for individualized management 2
No Bridging Therapy Required
- Do not use heparin bridging when interrupting apixaban 1
- The rapid offset (half-life 7-8 hours) and rapid onset of apixaban eliminates the need for bridging anticoagulation 1, 5
Common Pitfalls to Avoid
- Failing to account for renal function when determining hold duration increases bleeding or thrombotic risk 2
- Resuming anticoagulation too early after polypectomy (within 24 hours) significantly increases post-procedure bleeding risk 2, 6
- Using warfarin protocols for apixaban management is inappropriate—apixaban has predictable pharmacokinetics and does not require INR monitoring 1, 5
- Checking anti-Xa levels routinely is unnecessary unless there is clinical deterioration or concern for drug accumulation in renal impairment 1