DOACs & Endoscopy: Conservative Hold/Restart Windows (Colonoscopy, EGD)
This page is the canonical for endoscopy on DOACs (apixaban, rivaroxaban, edoxaban, dabigatran), including brand queries (Eliquis, Xarelto, Savaysa, Pradaxa). The approach is conservative and neuraxial-safe, aligned with MD Anderson V8 (2025). For the broader multi-drug frame, see the Conservative Peri-Procedure Plan. To convert the framework into exact timestamps by date/time and renal function, use the calculator.
Jump to: Risk tiers · Hold/restart windows · Scenarios · Edge cases · FAQ · Source
1) Endoscopic bleeding risk tiers (why this matters)
Endoscopic bleeding risk determines how long to hold and when to restart. DOACs have short half-lives; small changes in timing can materially shift risk. Classify the procedure before setting windows.
| Tier | Examples |
|---|---|
| Low / Moderate | Diagnostic colonoscopy or EGD ± biopsy; small cold-snare polypectomy |
| High | Hot snare polypectomy; EMR/ESD; ampullectomy; complex hemostasis; large piecemeal resections |
Plans sometimes shift intra-procedure (e.g., diagnostic → therapeutic). Choose a default that is safe if upgraded to high-risk.
2) Conservative windows (DOACs)
Below are the general patterns. They keep language non-prescriptive (no dosing) while providing actionable planning windows. Always integrate renal function and any neuraxial context.
Factor Xa inhibitors: apixaban, rivaroxaban, edoxaban
| Context | Typical hold | Notes |
|---|---|---|
| Low/Moderate-risk endoscopy | ~24 h | Common conservative approach for short procedures |
| High-risk endoscopy | ~48–72 h | Favor longer end for complex resections |
| Reduced renal function | Escalate holds | Conservative escalation if CrCl <30 for rivaroxaban/edoxaban; <25 for apixaban |
Dabigatran (thrombin inhibitor): hold by CrCl tier
| CrCl (mL/min) | Low/Moderate risk | High risk |
|---|---|---|
| ≥50 | ~1 day | ~2 days |
| 30–49 | ~2 days | ~3 days |
| <30 | ~4–5 days; consider avoiding elective endoscopy if possible | |
Restart windows (hemostasis first)
| Procedure tier | Typical restart | Notes |
|---|---|---|
| Low/Moderate | ~24 h | Ensure no active bleeding and secure hemostasis |
| High risk | ~48–72 h | Longer if extensive resection or delayed bleeding risk |
Neuraxial context (if applicable)
- No DOAC dosing while a neuraxial catheter is in place.
- Epidural/spinal gating: earliest restart is removal + a conservative interval; the actual restart is the later of that gate or the baseline window above.
- Dabigatran caution: avoid neuraxial if CrCl <30; escalate conservatively for others at very low CrCl.
Use the calculator to apply this frame to a specific date/time and to surface gating warnings so the restart never falls while a catheter is still in place.
3) Worked scenarios (calendar logic)
These examples show how the windows translate into timestamps. They are illustrations, not patient-specific advice.
Scenario A — Diagnostic colonoscopy (low/mod)
- Plan: Thursday 09:00, apixaban, CrCl 70.
- Hold: ~24 h → last pre-procedure dose should fall before Wednesday 09:00 so a full day elapses prior to the case.
- Restart: ~24 h after secure hemostasis → around Friday 09:00 if no bleeding concerns.
- Note: No bridging for DOACs. If biopsies are taken unexpectedly, this low/mod frame still applies.
Scenario B — Hot snare polypectomy (high risk)
- Plan: Tuesday 13:00, rivaroxaban, CrCl 55.
- Hold: ~48 h → stop such that Sunday 13:00 is the last time the window is open; ensure two full days elapse before Tuesday afternoon.
- Restart: ~48–72 h → earliest Friday 13:00 if hemostasis is secure; favor the longer end for extensive resections.
Scenario C — EMR with renal impairment on dabigatran
- Plan: Monday 08:00, CrCl 38 (high risk).
- Hold: ~3 days → last dose should precede Friday 08:00.
- Restart: ~48–72 h → not before Wednesday 08:00, and later if hemostasis is uncertain.
- Note: If CrCl drops below 30, elective EMR is often deferred; consider alternate strategies.
Scenario D — “Biopsy only” that upgrades mid-case
- Plan: Friday 10:00, edoxaban, CrCl normal; intended diagnostic scope but large polyp found.
- Hold: Start with a low/mod frame (~24 h). If the plan upgrades to hot snare/EMR, treat future cases as high-risk and extend to ~48–72 h on the front end.
- Restart: If therapeutic resection occurs, use the high-risk restart window (~48–72 h).
4) Edge cases & planning tips
- Unknown last dose: For truly urgent scopes, proceed with the safest feasible plan; otherwise clarify timing or reschedule to satisfy the conservative window.
- Weekend/Monday cases: 48–72 h holds commonly span weekends. Place reminders so the last dose isn’t taken “out of habit.”
- Missed pre-procedure dose: Do not “double up.” Maintain the conservative gap.
- Renal changes between scheduling and day-of: Recalculate; dabigatran is particularly sensitive to CrCl shifts.
- Post-polypectomy bleeding risk: For large, hot resections and piecemeal EMR/ESD, use the longer restart end (~72 h) and reassess before restarting.
5) Frequently asked questions
How long should we hold Eliquis (apixaban) before a colonoscopy?
For diagnostic or other low/moderate-risk scopes, many teams use ~24 h. For high-risk work (hot snare, EMR/ESD), ~48–72 h is common. Use longer ends for larger/complex resections or if bleeding risk is elevated.
When do we restart Xarelto (rivaroxaban) after polypectomy?
For high-risk resections, ~48–72 h after the procedure once hemostasis is secure. If extensive or piecemeal, many opt for the longer end of the window.
Do we bridge DOACs for endoscopy?
No. DOACs are not bridged in this context. If an exception is claimed (very high thrombotic risk), engage specialist input rather than defaulting to a bridge.
If biopsy is added to a diagnostic colonoscopy, does that change the plan?
Biopsy typically remains in the low/moderate tier. The ~24 h hold/restart pattern often applies. Reserve longer windows for high-risk resections.
How does renal function change dabigatran timing?
Dabigatran requires longer holds as CrCl declines: around 2–3 days at CrCl 30–49 depending on risk, and ~4–5 days if CrCl <30 (elective cases are often avoided in that range). Restarts still follow the low/mod vs high-risk pattern.
Source & governance
Primary reference: MD Anderson Peri-Procedure Anticoagulants, V8 (approved 07/15/2025), with neuraxial intervals cross-referenced to ASRA-derived institutional summaries when explicit catheter timings are not specified by MDACC. This content supports, not replaces, clinical judgment. Use local policy and confirm hemostasis before any restart.
Educational content. Supports, not replaces, clinical judgment. Confirm local policy/ASRA neuraxial guidance.