How should I manage anticoagulation and prepare a patient on apixaban (Eliquis) with a recent recurrent femoral‑vein deep vein thrombosis and falling hemoglobin for an esophagogastroduodenoscopy (EGD) and colonoscopy scheduled in two days?

Management Plan for EGD and Colonoscopy in 2 Days

Given the recent recurrent femoral-vein DVT (high thrombotic risk: <3 months after VTE) and falling hemoglobin suggesting active GI bleeding, you should NOT proceed with elective endoscopy in 2 days—instead, hold apixaban immediately, switch to therapeutic unfractionated heparin bridging, and perform urgent (not elective) endoscopy once hemodynamically stabilized. 1

Critical Risk Assessment

This patient has two competing life-threatening risks:

• High thromboembolic risk: Recent recurrent DVT on apixaban places this patient in the highest risk category (<3 months after VTE), which normally requires bridging anticoagulation when interrupting therapy 1
• Active bleeding risk: Falling hemoglobin indicates ongoing GI blood loss, making this an emergency rather than elective endoscopy scenario 1

Immediate Management Algorithm

Step 1: Reclassify This as Emergency Endoscopy

• The falling hemoglobin transforms this from "elective endoscopy in 2 days" to urgent/emergency endoscopy requiring immediate action 1
• Hold the last dose of apixaban immediately 1
• Do NOT wait 48 hours (the standard elective timing) to perform endoscopy 1

Step 2: Anticoagulation Bridge Strategy

For this high-risk VTE patient (<3 months post-DVT), bridging IS indicated despite the bleeding:

• Start therapeutic unfractionated heparin (UFH) infusion (80 U/kg bolus, then 18 U/kg/hour) rather than LMWH 1
• UFH is preferred over LMWH because its short half-life (1-2 hours IV) allows rapid reversal if rebleeding occurs during or after endoscopy 1
• The guideline explicitly states bridging is recommended for patients <3 months after VTE, even in bleeding scenarios 1

Step 3: Timing of Endoscopy

• Perform endoscopy as soon as hemodynamically stable, ideally within 12-24 hours 1
• Hold UFH 4-6 hours before endoscopy (based on aPTT normalization) 1
• Do NOT delay endoscopy waiting for complete normalization of coagulation parameters in life-threatening bleeding 1

Step 4: Peri-Procedural Management

During active bleeding with apixaban on board:

• If the last apixaban dose was <3 hours ago, consider activated charcoal (though likely not applicable given your 2-day timeline) 1
• Do NOT use vitamin K (ineffective for DOACs) 1
• Do NOT use platelet transfusion or desmopressin (no evidence of benefit and may increase mortality) 1
• Standard hemodynamic support measures are sufficient given apixaban's 12-hour half-life 1

Step 5: Post-Endoscopy Anticoagulation Resumption

After achieving adequate hemostasis:

• Resume UFH infusion 6-12 hours post-procedure if hemostasis is secure 1
• Transition back to apixaban once stable (typically after 24-48 hours of demonstrated hemostasis) 1
• Given the recurrent DVT on apixaban, strongly consider switching to therapeutic LMWH (e.g., enoxaparin 1 mg/kg subcutaneously every 12 hours) as the definitive anticoagulant, as this is the most effective strategy for recurrent VTE on DOACs 2

Critical Pitfall: The "No Bridging for DOACs" Guideline Does NOT Apply Here

The guidelines state "we do not recommend bridging therapy in patients on DOACs" for ELECTIVE procedures in standard-risk patients 1. However:

• This patient has BOTH active bleeding (emergency indication) AND high thrombotic risk (<3 months post-VTE) 1
• The bridging indication list explicitly includes "<3 months after VTE" as requiring bridging 1
• Emergency endoscopy for bleeding requires different management than elective procedures 1

Why Apixaban May Be Failing

Address potential causes of recurrent DVT on apixaban:

• Rule out drug interactions reducing apixaban efficacy (strong CYP3A4 inducers, P-glycoprotein inducers) 2, 3
• Assess for underlying malignancy, particularly GI or genitourinary cancer (given the bleeding and thrombosis) 1, 2
• Consider that patients with gastric/gastroesophageal tumors have increased hemorrhage risk with DOACs 1

Post-Procedure Long-Term Plan

After endoscopy and source control:

• Switch from apixaban to therapeutic LMWH (enoxaparin 1 mg/kg every 12 hours) for recurrent VTE management 2
• LMWH has superior efficacy for recurrent thrombosis, particularly if cancer is discovered 1, 2
• If LMWH is not feasible, consider switching to rivaroxaban, edoxaban, or warfarin (INR 2.0-3.0) 2
• Plan for indefinite anticoagulation given recurrent unprovoked DVT 2

Renal Function Considerations

• Verify creatinine clearance: apixaban should be avoided if CrCl <15 mL/min and used cautiously if CrCl <25 mL/min 1, 3
• If severe renal impairment exists, UFH is the preferred agent (hepatic metabolism) 1