How long should Eliquis (apixaban) be held prior to colonoscopy?

From the Guidelines

Eliquis (apixaban) should typically be held for 48 hours before a colonoscopy, as recommended by the most recent guidelines from the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 1. This recommendation applies to patients with normal renal function who are at standard risk for thromboembolism. For patients with impaired kidney function or those at high risk for bleeding, a longer interruption period may be necessary, but the specific duration should be determined based on individual patient factors and in consultation with their healthcare provider. The timing is based on apixaban's pharmacokinetics, with a half-life of approximately 12 hours, and the goal of minimizing bleeding risk while also considering the risk of thromboembolic events. After the colonoscopy, Eliquis can usually be resumed 24-48 hours following the procedure if no significant bleeding occurred, with the exact timing depending on whether any interventions were performed during the colonoscopy and the patient's individual bleeding risk. Key considerations include:

• Patient renal function, as measured by creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR) 1
• Thromboembolic risk, which may influence the decision to hold or resume anticoagulation therapy 1
• Bleeding risk, which is higher in patients with certain comorbidities or those undergoing high-risk procedures 1 Always consult with your healthcare provider for personalized guidance, as they may recommend bridging therapy with shorter-acting anticoagulants for high-risk patients. In general, the approach to managing anticoagulation therapy in patients undergoing colonoscopy should prioritize minimizing bleeding risk while also considering the risk of thromboembolic events, and should be individualized based on patient-specific factors.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

Eliquis (apixaban) should be held prior to colonoscopy for at least 48 hours if the procedure has a moderate or high risk of bleeding, and at least 24 hours if the procedure has a low risk of bleeding 2.

• The decision to hold Eliquis for 24 or 48 hours depends on the bleeding risk associated with the colonoscopy procedure.
• It is essential to consider the individual patient's risk factors and the specific procedure being performed when determining the duration of Eliquis hold.

From the Research

Eliquis (Apixaban) and Colonoscopy

• The management of anticoagulation during elective and emergency colonoscopy is a complex issue, and the decision to interrupt or continue anticoagulants like Eliquis (apixaban) will involve considerable exercise of clinical judgment 3.
• There is limited data on the specific timing of holding Eliquis prior to colonoscopy, but studies suggest that direct oral anticoagulants (DOACs) like apixaban have a rapid onset and offset of action, and periprocedural bridging is generally not necessary 3.
• A study published in 2022 found that apixaban was associated with a lower risk of post-polypectomy bleeding (PPB) and thromboembolism compared to warfarin and other DOACs like dabigatran and rivaroxaban 4.
• Another study published in 2011 found that the risk of hemorrhagic complications after colonoscopy with polypectomy was not significantly affected by the number of days that anticoagulation was held pre- or post-polypectomy, but the study did not specifically address Eliquis 5.
• The optimal timing of anticoagulation pre- and post-colonoscopy with polypectomy is not well established, and more studies are needed to refine guidelines for the management of anticoagulation during colonoscopy 6, 5.

Recommendations for Holding Eliquis

• Based on the available evidence, it is recommended that Eliquis be held for at least 24-48 hours prior to colonoscopy with polypectomy, but the exact timing may vary depending on the individual patient's risk factors and medical history 3, 4.
• The decision to hold Eliquis should be made on a case-by-case basis, taking into account the patient's risk of thromboembolism and bleeding, as well as the type of procedure being performed 3, 5.
• Patients should be closely monitored for signs of bleeding or thromboembolism after colonoscopy with polypectomy, and Eliquis should be restarted as soon as possible after the procedure to minimize the risk of thromboembolic events 4, 7.