What is the protocol for stopping Eliquis (apixaban) prior to an Esophagogastroduodenoscopy (EGD) and colonoscopy for a patient with a Deep Vein Thrombosis (DVT)?

Protocol for Stopping Eliquis Prior to EGD and Colonoscopy in a Patient with DVT

For a patient with DVT on Eliquis undergoing EGD and colonoscopy, stop apixaban 48 hours (2 days) before the procedure if performing biopsies or polypectomy, or omit only the morning dose for diagnostic procedures without intervention. 1

Risk Stratification of the Procedures

EGD and colonoscopy with biopsies or polypectomy are classified as high-risk procedures for bleeding. 1

• Diagnostic endoscopy with standard biopsies alone is considered low-risk 1
• Colonoscopy with polypectomy, endoscopic mucosal resection (EMR), or endoscopic submucosal dissection (ESD) are high-risk procedures 1
• The bleeding risk classification determines the duration of apixaban interruption 1

Preoperative Apixaban Interruption Protocol

For high-risk procedures (polypectomy, therapeutic interventions): Stop apixaban 48 hours (2 days) before the procedure. 1

• This means the last dose should be taken 2 days before the procedure, with no doses in the 48 hours preceding endoscopy 1
• For low-risk diagnostic procedures without intervention: Omit only the morning dose on the day of the procedure 1
• Do NOT extend the interruption period beyond 48 hours unless the patient has significant renal impairment (CrCl <50 mL/min), which would require individualized assessment 1

Renal Function Considerations

Check creatinine clearance before determining the exact timing, as renal impairment affects apixaban elimination. 1, 2

• For normal renal function (CrCl ≥50 mL/min): 48 hours off for high-risk procedures 1
• For CrCl 30-50 mL/min: Consider extending to 72 hours for high-risk procedures 1
• Apixaban is contraindicated in severe renal impairment (CrCl <30 mL/min for DVT treatment) 3

Thrombotic Risk Assessment

A patient with recent DVT is at high thrombotic risk, but bridging anticoagulation is NOT recommended when interrupting apixaban. 1, 4

• The rapid offset and onset of DOACs like apixaban eliminates the need for heparin bridging 1
• Bridging increases bleeding risk without reducing thrombotic complications 1, 4
• This is a critical distinction from warfarin management—do not bridge with LMWH or heparin 1

Postoperative Resumption

Resume apixaban once adequate hemostasis is achieved, typically 24-48 hours after high-risk procedures. 1, 3

• For low-risk diagnostic procedures: Can resume as early as 6-12 hours post-procedure 1, 4
• For high-risk procedures with polypectomy: Wait at least 24 hours and confirm no active bleeding 1
• The FDA label states apixaban should be restarted "as soon as adequate hemostasis has been established" 3
• Resume at the patient's usual DVT treatment dose (likely 5 mg twice daily if beyond the initial 7-day period of 10 mg twice daily) 3

Critical Pitfalls to Avoid

Do not use bridging anticoagulation with heparin products when stopping apixaban—this significantly increases bleeding risk without benefit. 1, 4

• Unlike warfarin, DOACs do not require bridging due to their rapid pharmacokinetics 1
• Do not check INR or anti-Xa levels routinely to guide timing—these are not reliable for apixaban management in this setting 1
• Ensure the procedure is not performed if there is any possibility of residual apixaban effect, particularly if neuraxial anesthesia is planned 2, 3
• Do not restart apixaban too early after polypectomy—delayed bleeding can occur up to 2 weeks post-procedure 5

Special Considerations for DVT Patients

The timing of the DVT relative to the procedure matters for risk stratification. 1

• Recent DVT (within 3 months) represents higher thrombotic risk 1
• However, even in high thrombotic risk patients, bridging is not indicated for DOAC interruption 1
• Consider postponing elective procedures if the DVT occurred within the past 1-2 weeks and the patient is still in the acute treatment phase 1

Algorithm Summary

1. Assess bleeding risk: Diagnostic only (low-risk) vs. polypectomy/biopsy (high-risk) 1
2. Check renal function: Calculate CrCl using Cockcroft-Gault formula 1, 2
3. Stop apixaban: 48 hours before high-risk procedures (72 hours if CrCl 30-50 mL/min), or omit morning dose only for low-risk 1
4. Do NOT bridge with heparin 1
5. Perform procedure when apixaban effect is minimal 1
6. Resume apixaban: 24-48 hours post-procedure once hemostasis confirmed 1, 3