When should a patient on Eliquis (apixaban), amiodarone, and Plavix (clopidogrel) hold these medications before undergoing EGD and colonoscopy?

Management of Antithrombotic Therapy for EGD and Colonoscopy

For this patient on Eliquis, amiodarone, and Plavix undergoing elective EGD and colonoscopy, hold Eliquis 48 hours before the procedure and hold Plavix 5 days before the procedure, while amiodarone should be continued throughout. 1

Critical Risk Assessment Required

Before implementing any medication holds, you must first determine the patient's thrombotic risk category, as this fundamentally changes management:

Very High Thrombotic Risk (Defer Procedure)

• Acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) within the last 6 weeks - the procedure should be deferred entirely if possible 1
• If the procedure cannot be deferred and falls into this timeframe, cardiology consultation is mandatory before stopping any antiplatelet agent 1

High Thrombotic Risk (6 weeks to 6 months post-ACS/PCI)

• Defer the procedure until >6 months after the cardiac event if clinically feasible 1
• If the procedure must proceed within this window, continue aspirin if the patient is on it, hold Plavix 5 days before, but consider heparin bridging for the anticoagulant 1

Moderate to Low Thrombotic Risk (>6 months post-ACS/PCI or stable CAD)

• Standard management applies as outlined below 1

Medication-Specific Management

Eliquis (Apixaban - DOAC)

• Hold for at least 48 hours before the procedure for high-risk procedures like colonoscopy with polypectomy and therapeutic EGD 1
• The FDA label confirms discontinuation 48 hours prior to elective surgery or invasive procedures with moderate or high bleeding risk 2
• No bridging anticoagulation is recommended - bridging with heparin is not indicated for DOACs and increases bleeding risk without reducing thrombotic events 1
• Resume Eliquis after adequate hemostasis is achieved, typically 24-48 hours post-procedure if no bleeding complications 1

Plavix (Clopidogrel - P2Y12 Inhibitor)

• Hold for 5 days before the procedure if the patient is at low-to-moderate thrombotic risk 1
• The 2018 APAGE/APSDE guidelines provide strong recommendations for this 5-day hold period for high-risk endoscopic procedures 1
• Never hold both antiplatelet agents simultaneously if the patient is on dual antiplatelet therapy (DAPT) - continue aspirin if present 1
• Resume Plavix after adequate hemostasis, preferably within 5 days post-procedure for patients with drug-eluting stents 1

Amiodarone

• Continue amiodarone throughout the perioperative period - this antiarrhythmic medication does not affect bleeding risk and should not be interrupted [@General Medicine Knowledge@]
• Amiodarone is not an antithrombotic agent and does not require adjustment for endoscopic procedures [@General Medicine Knowledge@]

Procedure-Specific Bleeding Risk

Both EGD and colonoscopy are considered high-risk procedures when therapeutic interventions are anticipated:

High-Risk Interventions Include:

• Polypectomy during colonoscopy 1
• EMR (endoscopic mucosal resection) or ESD (endoscopic submucosal dissection) 1
• Dilation of strictures 1
• Biopsy of varices or therapeutic interventions 1

Low-Risk Procedures:

• Diagnostic EGD or colonoscopy with standard mucosal biopsies only - in this scenario, antithrombotics could be continued 1

Timeline Summary

Pre-Procedure:

• Day -5: Last dose of Plavix (5 days before procedure) 1
• Day -2: Last dose of Eliquis (48 hours before procedure) 1
• Day of procedure: Continue amiodarone as scheduled [@General Medicine Knowledge@]

Post-Procedure:

• Day 0-1: Resume Eliquis once adequate hemostasis confirmed, typically 24-48 hours post-procedure 1
• Day 1-2: Resume Plavix once adequate hemostasis confirmed, ideally within 5 days for high-risk cardiac patients 1
• Throughout: Continue amiodarone without interruption [@General Medicine Knowledge@]

Critical Pitfalls to Avoid

Do Not Bridge the DOAC

• Bridging anticoagulation with heparin or LMWH is not recommended for DOACs and significantly increases bleeding risk without reducing thrombotic events 1
• This differs from warfarin management, where bridging may be indicated in high thrombotic risk patients 1

Do Not Stop Both Antithrombotics in High-Risk Cardiac Patients

• If this patient has recent stents or is within 6 months of ACS, never stop both the anticoagulant and antiplatelet simultaneously without cardiology consultation 1
• The risk of stent thrombosis is highest within the first 6 weeks and remains elevated until 6 months post-PCI 1

Verify Renal Function for DOAC Dosing

• If the patient has a creatinine clearance of 30-50 mL/min while on Eliquis, extend the hold to 72 hours before the procedure 1, 3
• Rapidly deteriorating renal function requires hematology consultation before proceeding 1, 3

Confirm Indication for Anticoagulation

• The combination of a DOAC (Eliquis) and antiplatelet (Plavix) suggests either atrial fibrillation with recent coronary intervention or another high-risk scenario 1
• Document the specific indication as this determines whether bridging might be needed (e.g., mechanical mitral valve, CHADS-VASc >5, recent VTE <3 months) 1

Special Consideration: Dual Pathway Inhibition

This patient is on both an anticoagulant (Eliquis) and an antiplatelet agent (Plavix), which represents dual pathway inhibition and carries higher bleeding risk:

• The 2018 APAGE/APSDE guidelines acknowledge that patients on combined anticoagulation and antiplatelet therapy require individualized assessment 1
• Communication with the prescribing cardiologist is essential to understand the indication and duration of dual therapy 1
• If the patient is beyond 12 months post-PCI and has stable coronary disease, consider whether Plavix can be discontinued permanently rather than just held temporarily 1