How to manage a patient on Eliquis (apixaban) with spontaneous gingival bleeding?

From the Guidelines

For a patient on Eliquis (apixaban) experiencing gum bleeding, the first step is to apply direct pressure to the bleeding area using a clean gauze or cloth for 15-20 minutes, as recommended by the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1. This approach is crucial in managing minor bleeding episodes.

• If bleeding persists beyond 30 minutes or is severe, seek immediate medical attention.
• Do not stop taking Eliquis without consulting a healthcare provider, as this could increase stroke risk.
• Contact the prescribing physician promptly to report the bleeding, as they may need to adjust the dosage or temporarily discontinue the medication.
• Avoid using aspirin, NSAIDs like ibuprofen, or other blood thinners that could worsen bleeding.
• Maintain good oral hygiene with a soft-bristled toothbrush and gentle flossing to prevent further gum irritation. According to the guidelines, if the bleeding is considered non-major, the patient should receive local therapy/manual compression, and the healthcare provider may consider continuing the oral anticoagulant (OAC) if there is an appropriate indication 1. In cases where the bleeding is major or life-threatening, more aggressive management strategies may be necessary, including the administration of reversal/hemostatic agents such as andexanet alfa for patients taking apixaban or rivaroxaban 1. It is essential to follow the specific guidelines for managing bleeding in patients on oral anticoagulants, as outlined in the 2020 ACC expert consensus decision pathway, to minimize the risk of morbidity, mortality, and to improve quality of life 1.

From the FDA Drug Label

Apixaban tablets increases the risk of bleeding and can cause serious, potentially fatal, bleeding [see Dosage and Administration (2. 1) and Adverse Reactions (6.1)]. Concomitant use of drugs affecting hemostasis increases the risk of bleeding. Discontinue apixaban tablets in patients with active pathological hemorrhage.

The patient should be discontinued from apixaban tablets due to active pathological bleeding, in this case, gum bleeding. Monitoring for signs and symptoms of blood loss is necessary, and the patient should be advised to report them immediately or go to an emergency room. Consider reversal of anticoagulant effect using an agent to reverse the anti-factor Xa activity of apixaban, such as prothrombin complex concentrate (PCC), activated prothrombin complex concentrate, or recombinant factor VIIa, although these have not been evaluated in clinical studies 2 2.

From the Research

Treatment of Bleeding in Patients on Eliquis

• The management of severe bleeding in patients treated with oral anticoagulants, such as apixaban (Eliquis), requires a comprehensive approach 3.
• For patients with major bleeding associated with the use of apixaban, intravenous administration of andexanet alfa can effectively and rapidly reduce anti-factor Xa levels 4.
• Andexanet alfa acts as a decoy and competes with endogenous factor Xa to bind factor Xa inhibitors, thereby reversing the anticoagulant effects of factor Xa inhibitors, and restoring the activity of endogenous factor Xa 4.
• The replacement of blood components, including red blood cells, platelets, and clotting factors, is also a critically important initial treatment for patients with major bleeding 3.
• Reversing the anticoagulated state is necessary, and for patients treated with apixaban, andexanet alfa has been demonstrated to reverse the hypocoagulable state of the patient to allow blood clotting 3.

Bleeding Risk with Apixaban

• Apixaban is associated with a lower risk of bleeding than vitamin K antagonists (VKAs) 5.
• A meta-analysis of randomized controlled trials found that apixaban was associated with reduced risks of any bleeding and a composite of major or clinically relevant nonmajor bleeding 5.
• Apixaban was also associated with a lower risk of intracranial bleeding 5.
• However, bleeding is still a potential adverse event in patients taking apixaban, and its management requires careful consideration 6.

Resumption of Anticoagulation

• After effective treatment of severe bleeding, resumption of oral anticoagulation is important to prevent thrombotic complications 3.
• The clinician should consider the risks and benefits of resuming anticoagulation and make a decision based on the individual patient's needs 3.