Can Endoscopic Variceal Ligation (EVL) be performed on a patient taking Eliquis (apixaban)?

Can EVL Be Performed on Eliquis (Apixaban)?

Yes, EVL can be performed on patients taking Eliquis, but the anticoagulant must be discontinued 2-3 days (48-72 hours) before the procedure to minimize bleeding risk, with timing adjusted based on renal function. 1, 2

Hemorrhagic Risk Classification

EVL is classified as a high hemorrhagic risk procedure because:

• It creates post-banding ulcers at ligation sites that bleed in approximately 14% of cases 3
• Surgical hemostasis cannot be performed safely on anticoagulation 1
• Severe complications such as ulcer bleeding at the ligation site are more likely with EVL compared to medical therapy 1

Apixaban Discontinuation Protocol

Standard Timing (CrCl >50 mL/min)

• Stop apixaban 48 hours (2 days) before EVL 2
• The last dose should be taken 2 days prior to the procedure 1

Adjusted Timing for Renal Impairment (CrCl 30-50 mL/min)

• Extend discontinuation to 72 hours (3 days) before EVL 2
• This accounts for slower drug clearance in reduced renal function 1

Very High Risk Considerations

• For patients with additional risk factors (age >80 years, P-glycoprotein inhibitors, or CYP3A4 inhibitors), consider extending discontinuation up to 5 days 1

Critical Management Points

No Bridging Anticoagulation Required

• Do not use heparin bridging when stopping apixaban for EVL 2
• Bridging significantly increases bleeding risk without benefit due to the rapid offset of DOACs 2
• The only exception would be patients at very high thrombotic risk, which requires multidisciplinary discussion 1

Post-Procedure Resumption

• Resume apixaban 48-72 hours after EVL once adequate hemostasis is achieved 2
• For emergency/urgent EVL with active bleeding, timing must balance hemostasis against thrombotic risk 1

Bleeding Risk Mitigation Strategies

Proton Pump Inhibitor Therapy

• Administer PPIs after EVL to reduce post-banding ulcer size and bleeding risk 3, 4
• Pantoprazole 40 mg IV after EVL, followed by 40 mg oral daily for 9 days significantly reduces ulcer size 3, 4
• However, use PPIs cautiously in cirrhotic patients due to increased risk of spontaneous bacterial peritonitis and hepatic encephalopathy with long-term use 1

Recent Evidence on Anticoagulation During EVL

• A 2025 meta-analysis found that concurrent anticoagulation during EVL did not increase overall rebleeding risk (OR 1.10,95%CI 0.85-1.42) or post-banding ulcer bleeding (OR 1.04,95%CI 0.48-2.24) 5
• However, this evidence is of low certainty and included primarily low-molecular-weight heparin and warfarin, not DOACs 5
• Given the high-quality guideline recommendations and the low certainty of this contradictory evidence, the safer approach remains discontinuing apixaban before elective EVL 1, 2

Common Pitfalls to Avoid

• Failing to obtain recent creatinine clearance before determining hold duration can lead to inadequate drug clearance 1
• Not accounting for drug interactions with P-glycoprotein or CYP3A4 inhibitors may result in higher than expected apixaban levels 1
• Performing EVL with possible residual apixaban concentration due to insufficient discontinuation time significantly increases bleeding risk 1
• Unnecessarily prolonged discontinuation beyond recommended timeframes increases thrombotic risk without additional bleeding benefit 1

Emergency EVL Considerations

For acute variceal hemorrhage requiring urgent EVL:

• EVL should be performed within 12 hours of admission regardless of anticoagulation status, as this is a life-threatening emergency 1
• Vasoactive drugs (terlipressin, somatostatin, or octreotide) should be administered for 3-5 days 1
• Antibiotic prophylaxis with ceftriaxone 1g/24h for up to 7 days is mandatory 1
• The combination of endoscopic therapy and vasoactive drugs is the standard of care 1