What are the recommended washout periods for Eliquis (apixaban) and Plavix (clopidogrel) before a scope procedure?

Washout Periods for Eliquis and Plavix Before Endoscopy

For Eliquis (apixaban), stop 48 hours before high-risk endoscopic procedures and 24 hours before low-risk procedures; for Plavix (clopidogrel), stop 5 days before high-risk procedures while continuing aspirin if on dual antiplatelet therapy. 1

Eliquis (Apixaban) Management

Low-Risk Endoscopic Procedures

• Omit only the morning dose on the day of the procedure (approximately 24 hours from last dose) 1
• Low-risk procedures include diagnostic endoscopy with biopsies, biliary/pancreatic stenting, and device-assisted enteroscopy without polypectomy 1

High-Risk Endoscopic Procedures

• Stop Eliquis 3 days (72 hours) before the procedure 1, 2
• High-risk procedures include polypectomy, ERCP with sphincterotomy, EMR/ESD, variceal therapy, PEG placement, and stricture dilation 1
• The timing remains consistent regardless of renal function as long as creatinine clearance is >30 mL/min, since apixaban has less renal elimination than dabigatran 2

Special Renal Considerations

• For patients with CrCl 30-50 mL/min, the standard 3-day washout still applies for apixaban (unlike dabigatran which requires 5 days) 1, 2
• If renal function is rapidly deteriorating, consult hematology before proceeding 1

Plavix (Clopidogrel) Management

High-Risk Endoscopic Procedures

• Stop clopidogrel 5 days before the procedure 1
• This 5-day washout allows for adequate dissipation of the irreversible antiplatelet effect 1

Dual Antiplatelet Therapy (DAPT) Considerations

• Continue aspirin while stopping clopidogrel 5 days before high-risk procedures 1
• Never stop both antiplatelet agents simultaneously, as this dramatically increases thrombotic risk 1
• For patients with coronary stents placed within 6-12 weeks, liaise with cardiology about the risk/benefit of stopping clopidogrel versus continuing both agents 1

Low-Risk Endoscopic Procedures

• Do not discontinue clopidogrel for low-risk procedures 1
• Mucosal biopsies can be safely performed while continuing antiplatelet therapy 1

Resumption After Endoscopy

Eliquis Resumption

• Resume within 24-48 hours after the procedure once adequate hemostasis is achieved 1, 2
• For low bleeding risk procedures, can resume as early as 6 hours post-procedure 2
• For high bleeding risk procedures, delay 24-48 hours until hemostasis is secure 1

Plavix Resumption

• Resume clopidogrel within 24 hours after the procedure once adequate hemostasis is achieved 1
• Earlier resumption (within 24 hours) is preferred over delayed resumption to minimize thrombotic risk 1

Critical Pitfalls to Avoid

• Never use bridging anticoagulation with heparin or LMWH when stopping Eliquis, as this increases bleeding risk without reducing thrombotic risk 2, 3
• Do not stop both antiplatelet agents in patients on DAPT—continue aspirin while holding clopidogrel 1
• Do not perform high-risk procedures if INR >1.5 in patients transitioning from warfarin 1
• Avoid stopping clopidogrel in patients with recent coronary stents (<6-12 weeks) without cardiology consultation, as stent thrombosis risk is prohibitive 1

Risk Stratification Framework

High Thrombotic Risk Patients (Require Cardiology Consultation)

• Drug-eluting stents within 12 months 1
• Bare metal stents within 1 month 1
• Recent acute coronary syndrome (<3 months) 1
• Prosthetic metal heart valve in mitral position 1

Low Thrombotic Risk Patients (Standard Washout Applies)

• Ischemic heart disease without stents 1
• Cerebrovascular disease 1
• Peripheral vascular disease 1
• Atrial fibrillation without valvular disease 1