How long should apixaban (Eliquis) be discontinued before a low‑risk screening colonoscopy versus a therapeutic colonoscopy, and how should the timing be adjusted for impaired renal function or high thromboembolic risk?

Eliquis Discontinuation Before Colonoscopy

For a low-risk screening colonoscopy, omit only the morning dose of Eliquis on the day of the procedure; for a therapeutic colonoscopy with polypectomy or other high-risk interventions, stop Eliquis 3 days (72 hours) before the procedure. 1

Risk Stratification of Colonoscopy Procedures

The bleeding risk determines the management strategy:

• Low-risk procedures include diagnostic colonoscopy with or without mucosal biopsies 1
• High-risk procedures include colonoscopic polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) 1

Management for Low-Risk Screening Colonoscopy

Simply omit the morning dose on the day of the procedure 1, 2:

• Take the usual evening dose the night before the procedure 2
• Skip the morning dose on procedure day 1, 2
• Resume Eliquis 1 day after the procedure 2
• This approach carries a major bleeding rate of 1.35% and arterial thromboembolism rate of 0.16% 2

Management for High-Risk Therapeutic Colonoscopy

Stop Eliquis 3 days (72 hours) before the procedure 1, 2:

• The last dose should be taken 3 days prior to the procedure, allowing approximately 4-5 half-lives for drug elimination 1, 2
• Resume Eliquis 2-3 days after the procedure once adequate hemostasis is established 1, 2

Adjustments for Renal Impairment

For patients with normal renal function (CrCl >50 mL/min), no adjustment to the 3-day discontinuation is needed 1:

• Apixaban is only 25% renally cleared, so the FDA does not require dose adjustment based on renal function for procedural interruption 2
• However, if the patient has a CrCl of 30-50 mL/min on dabigatran (not apixaban), extend the discontinuation to 5 days 1
• For rapidly deteriorating renal function, consult hematology before proceeding 1, 2

High Thromboembolic Risk Considerations

Do not use bridging anticoagulation with heparin or low-molecular-weight heparin (LMWH) during the Eliquis interruption period 2:

• Bridging increases major hemorrhage rates without reducing thromboembolism 2
• High thromboembolic risk conditions include mechanical heart valves in mitral position, atrial fibrillation with mitral stenosis, and recent venous thromboembolism (<3 months) 1
• Even in high-risk patients, the BSG/ESGE guidelines recommend against bridging for DOACs 2

Common Pitfalls to Avoid

• Do not confuse the timing for warfarin (5 days) with DOACs like Eliquis (3 days for high-risk procedures) 1
• Do not automatically bridge all high-risk patients—bridging is not recommended for DOACs 2
• Do not delay resumption unnecessarily—restart within 1-3 days depending on hemostasis to minimize thrombotic risk 1, 2
• Do not forget to verify the procedure risk category—a screening colonoscopy without planned polypectomy is low-risk and requires only omitting the morning dose 1