How long before a colonoscopy should I hold apixaban (Eliquis), and does renal function or high thrombotic risk alter the timing?

Stopping Apixaban Before Colonoscopy

For colonoscopy with polypectomy (high bleeding risk), stop apixaban 48 hours (2 days) before the procedure in patients with normal or mildly impaired renal function (CrCl ≥50 mL/min), which allows 4 half-lives to elapse and reduces residual anticoagulant effect to approximately 6%. 1, 2

Preoperative Discontinuation Strategy

Standard Renal Function (CrCl ≥50 mL/min)

• Colonoscopy with biopsy only (low-moderate risk): Stop apixaban 24 hours (1 day) before the procedure, skipping 2 doses if taking twice daily 1, 2
• Colonoscopy with polypectomy (high bleeding risk): Stop apixaban 48 hours (2 days) before the procedure, skipping 4 doses 1, 2, 3
• The FDA label specifically states apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding 3

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

• High bleeding risk procedures: Extend discontinuation to 72 hours (3 days) before colonoscopy with polypectomy 4, 1
• Apixaban has 25% renal clearance, and moderate renal dysfunction prolongs the half-life to approximately 10-12 hours, necessitating longer interruption 1, 2

Severe Renal Impairment (CrCl <30 mL/min)

• Minimum 72 hours discontinuation is required, though evidence in this population is limited 1
• Consider drug-specific anti-Xa level measurement to confirm adequate clearance before proceeding 1

Critical Considerations

Bleeding Risk Classification

• High bleeding risk includes polypectomy, sphincterotomy, laser therapy, mucosal ablation, and variceal treatment 4, 5
• Low-moderate bleeding risk includes diagnostic colonoscopy with biopsy only 4, 1
• Research demonstrates that polypectomy carries a 2.2% bleeding risk overall, with warfarin increasing this risk 13-fold 6

Bridging Anticoagulation

• Do not use heparin or LMWH bridging during the apixaban interruption period 1, 2, 3
• The FDA label explicitly states "bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required" 3
• High-quality evidence from the PAUSE trial showed bridging increases major bleeding risk (2-5%) without reducing thrombotic events 2
• The only exception would be extremely high thrombotic risk situations (mechanical mitral valve, stroke within past month) requiring multidisciplinary review 2

Postoperative Resumption

Timing Based on Procedure Risk

• Diagnostic colonoscopy or simple biopsy: Resume apixaban 24 hours after the procedure at the usual dose (5 mg twice daily), ensuring at least 6 hours have elapsed and adequate hemostasis is established 1, 2, 3
• Colonoscopy with polypectomy: Resume apixaban 48-72 hours after the procedure once hemostasis is confirmed 1, 2
• For high thrombotic risk patients, consider reduced dose (2.5 mg twice daily) for the first 2-3 days, then return to full dose 1, 2

Safety Considerations

• Apixaban reaches peak effect within 1-3 hours of administration, so premature resumption can precipitate bleeding 1
• Research shows that resuming anticoagulation 1 day post-polypectomy did not significantly increase bleeding rates in retrospective series 7
• If therapeutic apixaban must be delayed beyond 48 hours in high thrombotic risk patients, use prophylactic-dose LMWH for the first 2-3 days 2

Common Pitfalls and Caveats

Laboratory Monitoring

• Do not use INR or aPTT to guide timing—these tests are insensitive to apixaban effect 1, 2
• Anti-factor Xa assays correlate with apixaban exposure but are not needed when standardized interruption protocols are followed 1, 2

Renal Function Assessment

• Mandatory calculation of creatinine clearance before determining interruption length, as moderate-to-severe impairment significantly prolongs apixaban elimination 1, 2
• Patients with declining renal function require extended preoperative interruption even if baseline function was acceptable 1

Timing Errors

• Excessively long interruption (>3-4 days in normal renal function) raises thromboembolic risk without additional bleeding protection 1
• Premature resumption before adequate hemostasis markedly increases major bleeding risk without lowering thrombotic events 2
• The British Society of Gastroenterology notes that polypectomy bleeding rates in anticoagulated patients (14-23%) far exceed rates in non-anticoagulated patients (0.07-1.7%) 4