Does a patient with atrial fibrillation (A. fib) on a Direct Oral Anticoagulant (DOAC) need to hold their anticoagulant before a colonoscopy?

Management of DOACs Before Colonoscopy in Atrial Fibrillation Patients

For patients with atrial fibrillation on DOACs undergoing colonoscopy, you must hold the anticoagulant before the procedure, with the specific timing dependent on whether polypectomy or other therapeutic interventions are planned.

Risk Stratification of the Procedure

The first critical step is determining the bleeding risk of your planned colonoscopy:

• Low-risk procedures (diagnostic colonoscopy with biopsies only): These carry minimal bleeding risk 1
• High-risk procedures (polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, stricture dilation): These require DOAC interruption 1

DOAC Management for High-Risk Colonoscopy Procedures

For high-risk endoscopic procedures including colonoscopy with polypectomy, hold the last dose of DOACs at least 48 hours before the procedure 1. This translates to skipping 2-4 doses depending on the specific DOAC:

• Apixaban: Skip 2 doses (last dose 48 hours pre-procedure) 1
• Rivaroxaban: Skip 1 dose (last dose 48 hours pre-procedure) 1
• Edoxaban: Skip 1 dose (last dose 48 hours pre-procedure) 1
• Dabigatran with normal renal function (CrCl >50 mL/min): Skip 2 doses (last dose 48 hours pre-procedure) 1

Special Consideration for Dabigatran and Renal Impairment

For patients on dabigatran with CrCl 30-50 mL/min, extend the interruption to 72 hours (skip 4 doses) before the procedure 1. If renal function is rapidly deteriorating, consult hematology before proceeding 1.

DOAC Management for Low-Risk Diagnostic Colonoscopy

For purely diagnostic colonoscopy with biopsies only, the evidence suggests these can be performed without interrupting DOACs, though many practitioners still opt for brief interruption (24 hours) for added safety 1.

Bridging Anticoagulation: Not Recommended

Do not bridge with low molecular weight heparin (LMWH) when interrupting DOACs for colonoscopy 1. The short half-life of DOACs makes bridging unnecessary and increases bleeding risk. Bridging should only be considered in the rare circumstance of active acute coronary syndrome 1.

Assessing Thrombotic Risk

While you must hold DOACs for high-risk procedures, recognize that atrial fibrillation without valvular disease is classified as low thrombotic risk for brief anticoagulation interruption 1. This makes the 48-72 hour interruption acceptably safe from a stroke perspective.

The 2024 ESC guidelines emphasize that bleeding risk scores should not be used to decide whether to withhold anticoagulation entirely—they are for optimizing management, not for avoiding necessary anticoagulation 1.

Resuming Anticoagulation Post-Procedure

Resume the DOAC within 24-48 hours after colonoscopy, depending on hemostasis and bleeding risk 1. Specifically:

• If hemostasis is adequate and no active bleeding: Resume within 24 hours 1
• If there was significant intervention or concern for delayed bleeding: Wait up to 48 hours 1
• For polypectomy specifically, resuming anticoagulation within 1-3 days post-procedure has been shown to be safe 2

The 2016 BSG/ESGE guidelines provide moderate quality evidence supporting resumption up to 48 hours post-procedure based on individual bleeding and thrombotic risk assessment 1.

Common Pitfalls to Avoid

• Do not use bleeding risk scores to justify withholding anticoagulation entirely—the 2024 ESC guidelines explicitly state this leads to under-use of necessary anticoagulation 1
• Do not continue DOACs uninterrupted for high-risk therapeutic colonoscopy—this significantly increases bleeding risk 1
• Do not delay resumption beyond 48 hours without compelling reason—prolonged interruption increases stroke risk without additional bleeding benefit 1
• Do not add antiplatelet therapy to anticoagulation for stroke prevention—this only increases bleeding risk without benefit 1

Algorithm Summary

1. Classify procedure risk: Diagnostic only (low) vs. polypectomy/therapeutic intervention (high) 1
2. For high-risk procedures: Hold DOAC for 48 hours (72 hours for dabigatran with CrCl 30-50) 1
3. No bridging with LMWH 1
4. Resume DOAC 24-48 hours post-procedure based on hemostasis 1
5. Continue long-term anticoagulation based on CHA₂DS₂-VASc score regardless of procedure 1