How long should apixaban (a direct oral anticoagulant) be stopped before a cystoscopy procedure in a patient with impaired renal function?

Apixaban Discontinuation Before Cystoscopy

For cystoscopy, stop apixaban 48 hours (2 days) before the procedure if renal function is normal, or 72 hours (3 days) before if creatinine clearance is 30-50 mL/min. 1

Bleeding Risk Classification

Cystoscopy is classified as a high-risk bleeding procedure when therapeutic interventions are performed (e.g., tumor resection, biopsy), similar to other endoscopic procedures with polypectomy. 1

Discontinuation Timeline Based on Renal Function

Normal Renal Function (CrCl >50 mL/min)

• Last dose: 48 hours (2 days) before cystoscopy 1
• This corresponds to approximately 4 half-lives, achieving minimal residual anticoagulant effect 2, 3
• The FDA label supports discontinuation at least 48 hours prior to procedures with moderate or high bleeding risk 4

Moderate Renal Impairment (CrCl 30-50 mL/min)

• Last dose: 72 hours (3 days) before cystoscopy 1, 5
• Apixaban has 27% renal clearance, making elimination significantly prolonged with reduced kidney function 2, 5, 6
• The European Heart Rhythm Association guidelines confirm 48-hour discontinuation for Factor Xa inhibitors (including apixaban) even with moderate renal impairment, though endoscopy guidelines extend this to 72 hours for added safety 1

Severe Renal Impairment (CrCl 15-29 mL/min)

• Last dose: 72 hours (3 days) or longer before cystoscopy 1
• Consider hematology consultation if renal function is rapidly deteriorating 1

Critical Considerations

Renal function assessment is mandatory before determining the discontinuation timeline. 5 Even if baseline renal function was acceptable, declining kidney function requires extended preoperative interruption. 3

Low-Risk Diagnostic Cystoscopy

If the cystoscopy is purely diagnostic without planned therapeutic intervention:

• Omit only the morning dose on the day of the procedure 1
• This approach is supported by the PAUSE trial, which demonstrated safety with 24-hour interruption for low-risk procedures 1

Bridging Anticoagulation

Do not bridge with heparin or low molecular weight heparin during the 48-72 hour interruption period. 1, 2, 3, 5, 4 Bridging increases major bleeding risk (6.5% vs 1.8%) without reducing thromboembolism rates. 1 Apixaban's predictable pharmacokinetics and rapid offset eliminate the need for bridging. 1, 2

Postoperative Resumption

• Resume apixaban 24-48 hours after cystoscopy once adequate hemostasis is established 1, 5
• For high-risk therapeutic procedures, consider waiting 48-72 hours before resumption 1
• Apixaban has rapid onset of action (full effect within 3 hours), so premature resumption risks bleeding if hemostasis is incomplete 1, 3

Common Pitfalls to Avoid

• Do not use INR or aPTT to guide timing - these tests are unreliable for monitoring apixaban effect 1, 2, 3
• Do not double the dose if a dose is missed during the discontinuation period 4
• Avoid concomitant use of P-gp and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir) during the perioperative period, as these prolong apixaban elimination 4
• Check for rapidly deteriorating renal function in any clinically unstable patient before proceeding 1

Evidence Strength

The 2021 BSG/ESGE guidelines provide strong recommendations for the 3-day discontinuation in high-risk endoscopic procedures, supported by the PAUSE trial (3,007 patients) which demonstrated low rates of major bleeding (1.35%) and arterial thromboembolism (0.16%). 1 The 2018 European Heart Rhythm Association guidelines align with these recommendations for Factor Xa inhibitors. 1