Should apixaban (Eliquis) be stopped before a non‑urgent colonoscopy scheduled in three days for a patient with atrial fibrillation with pacemaker who recently had a gastrointestinal bleed?

Should Eliquis Be Stopped Before Non-Urgent Colonoscopy?

Yes, apixaban (Eliquis) should be stopped 48 hours (2 days) before the colonoscopy, as colonoscopy is classified as a high-risk bleeding procedure, particularly given this patient's recent GI bleed history. 1

Timing of Apixaban Discontinuation

• Stop apixaban 48 hours prior to the colonoscopy for procedures with moderate or high risk of bleeding, which includes colonoscopy with potential polypectomy. 1
• The last dose should be taken on the morning 2 days before the procedure, corresponding to approximately 4 half-lives of drug elimination, resulting in minimal residual anticoagulant effect at the time of colonoscopy. 2
• For patients with moderate renal impairment (CrCl 30-50 mL/min), consider extending the interruption period to 3-4 days, as apixaban has 25% renal clearance and impaired renal function delays drug elimination. 2

Why Colonoscopy Is High-Risk in This Context

• Colonoscopy is classified as a high-risk bleeding procedure by both the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy, particularly when polypectomy may be performed. 3
• This patient's recent GI bleed further elevates bleeding risk, making anticoagulation interruption essential rather than optional. 4
• The risk of hemorrhagic complications increases with therapeutic interventions like hot biopsy or snare polypectomy during colonoscopy. 5

Critical Management Details

No Bridging Anticoagulation Required

• Do not use heparin or low molecular weight heparin bridging during the interruption period, as the rapid offset and rapid onset of action of apixaban obviates the need for bridging. 2
• Bridging increases major bleeding risk without reducing stroke or systemic embolism in this context. 2
• This differs from warfarin management in high thrombotic risk patients, where bridging may be indicated. 3

Thrombotic Risk Consideration

• While this patient has atrial fibrillation with a pacemaker, the 48-hour interruption of apixaban poses minimal thrombotic risk compared to the substantial bleeding risk of proceeding with anticoagulation. 1
• The presence of a pacemaker does not change anticoagulation management, as the indication for anticoagulation is the atrial fibrillation itself, not the pacemaker. 4

Resumption of Apixaban Post-Procedure

• Resume apixaban 48-72 hours after colonoscopy once adequate hemostasis is established and at least 6 hours after the end of the procedure. 2, 1
• Given this patient's recent GI bleed history, optimal timing for resumption is approximately 32 days after achieving hemostasis from a GI bleed, though the non-urgent colonoscopy in 3 days suggests the acute bleeding has already resolved. 6
• If polypectomy is performed during the colonoscopy, resuming anticoagulation 1-3 days post-procedure has been shown to be safe in clinical practice. 7
• Consider starting with a reduced dose (2.5 mg twice daily) for the first 2-3 days in patients at high thromboembolism risk, though this is not standard practice. 2

Common Pitfalls to Avoid

• Do not continue apixaban through the procedure, as this significantly increases bleeding risk, particularly if polypectomy is required. 3
• Do not assume adequate drug clearance without considering renal function—verify creatinine clearance before finalizing the interruption plan, as patients with declining renal function can accumulate apixaban and experience catastrophic bleeding complications. 2
• Do not delay the colonoscopy unnecessarily—the procedure is already scheduled for 3 days out, which provides adequate time for a 48-hour interruption if apixaban is stopped immediately. 1