How long before an endometrial biopsy should a patient with impaired renal function, taking Eliquis (apixaban), stop the medication and when can it be resumed?

Management of Eliquis (Apixaban) for Endometrial Biopsy

For patients with impaired renal function undergoing endometrial biopsy, stop Eliquis 48 hours before the procedure (with normal renal function) or 72 hours before if creatinine clearance is 30-50 mL/min, and resume within 6-48 hours after the procedure once adequate hemostasis is achieved.

Risk Stratification of Endometrial Biopsy

Endometrial biopsy is classified as a low-risk procedure for bleeding according to BSG/ESGE guidelines, falling under "diagnostic procedures ± biopsy" 1. This classification is critical because it determines the duration of anticoagulation interruption needed.

Pre-Procedure Management: When to Stop Eliquis

For Patients with Normal Renal Function (CrCl >50 mL/min)

• Stop Eliquis 48 hours before the procedure (skip 4 doses if taking twice daily) 1
• The FDA label confirms that apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding 2
• For truly low-risk procedures where bleeding would be minimal, the FDA allows stopping 24 hours prior, though 48 hours is more conservative 2

For Patients with Impaired Renal Function (CrCl 30-50 mL/min)

• Stop Eliquis 72 hours before the procedure (skip 6 doses if taking twice daily) 1
• This extended interruption is necessary because apixaban clearance is prolonged with renal impairment, though less so than dabigatran since only 25% of apixaban is renally eliminated 3
• The BSG/ESGE guidelines specifically state this 72-hour recommendation applies to dabigatran with CrCl 30-50 mL/min, but the principle of extended interruption applies to all DOACs in renal impairment 1

Special Considerations for Severe Renal Impairment

• If renal function is rapidly deteriorating, consult a hematologist before proceeding 1
• Monitor for signs of anticoagulant-related nephropathy, as apixaban initiation has been associated with acute kidney injury aggravation in case reports 4

Alternative Approach for Low-Risk Procedures

For endometrial biopsy specifically, given its classification as a low-risk procedure:

• Consider simply omitting the morning dose on the day of the procedure if the patient has normal renal function and low thrombotic risk 1
• This approach allows the biopsy to be performed at trough apixaban levels, minimizing anticoagulant effect while avoiding prolonged interruption 1
• However, the more conservative 48-hour interruption is safer and more widely recommended 1

Post-Procedure Management: When to Resume Eliquis

Standard Resumption Protocol

• Resume Eliquis 6-48 hours after the procedure depending on bleeding risk and adequacy of hemostasis 1
• The FDA label states apixaban should be restarted "as soon as adequate hemostasis has been established" 2
• For twice-daily dosing, resume the evening of the procedure day if hemostasis is secure 5

Specific Timing Recommendations

• Minimum 6 hours post-procedure if there is no active bleeding and hemostasis is adequate 6, 5
• Wait 24-48 hours if there are concerns about delayed bleeding or if hemostasis is uncertain 6
• The BSG/ESGE guidelines recommend resumption "up to 48 hours after the procedure depending on the perceived bleeding and thrombotic risks" 1

Critical Pitfalls to Avoid

Never Use Bridging Anticoagulation

• Do not bridge with heparin or LMWH when stopping Eliquis for endometrial biopsy 6, 5
• Bridging dramatically increases bleeding risk without reducing thrombotic risk 6, 5, 7
• The FDA label confirms that "bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required" 2

Assess Thrombotic Risk

• Determine if the patient is at high thrombotic risk (mechanical heart valve, recent VTE <3 months, recent coronary stent) 1
• For high thrombotic risk patients, the shorter interruption period may be preferable, or consultation with cardiology/hematology is warranted 1
• However, DOACs like apixaban are contraindicated in mechanical heart valves, so this scenario should not arise 1

Monitor Renal Function

• Check creatinine clearance before determining the interruption period 1
• Renal function can deteriorate with apixaban use, particularly in patients with preexisting kidney disease 4
• If CrCl is not recently documented, calculate it before making the interruption plan 1

Practical Algorithm

1. Assess renal function (calculate CrCl or use eGFR)
2. If CrCl >50 mL/min: Stop Eliquis 48 hours before biopsy
3. If CrCl 30-50 mL/min: Stop Eliquis 72 hours before biopsy
4. If CrCl <30 mL/min or rapidly declining: Consult hematology
5. Perform endometrial biopsy with local hemostatic measures as needed
6. Resume Eliquis 6-24 hours post-procedure if hemostasis is adequate, or wait up to 48 hours if bleeding concerns exist
7. Never use bridging anticoagulation with heparin products