What is a safe plan for resuming apixaban (eliquis) in a patient with resolving diverticulitis, stable hemoglobin levels, and normal vital signs, who has been on ceftriaxone (Rocephin) and metronidazole (Flagyl), and has had apixaban (eliquis) held during admission?

From the Guidelines

For a patient with resolving diverticulitis who has been stable for 6 days, apixaban can be safely resumed once the risk of bleeding has decreased, and I recommend restarting apixaban at the patient's regular dose the day after discharge, approximately 24 hours after the last dose of antibiotics. According to the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1, the decision to restart anticoagulation depends on whether the bleed is considered major or non-major. In this case, since the patient has been stable for 6 days with no signs of active bleeding, hemodynamic instability, or clinically overt bleeding with hemoglobin decrease ≥2 g/dL, the bleed can be considered non-major.

Before discharge, it is essential to ensure the patient has no signs of active bleeding, has stable vital signs, and hemoglobin remains stable. The patient should complete the full course of oral antibiotics (typically amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 7-10 days total). Key factors to consider before resuming apixaban include:

• The patient's clinical indication for continued oral anticoagulation (OAC)
• The risk of rebleeding or death/disability with rebleeding
• The identification of the source of bleed
• Planned surgical or invasive procedures
• The patient's wish to restart OAC

Since the patient has been stable and there are no indications of a high risk of rebleeding or other contraindications, resuming apixaban is reasonable. Provide clear instructions to the patient about signs of recurrent bleeding that would warrant immediate medical attention, including severe abdominal pain, bloody stools, dizziness, or shortness of breath. The timing of apixaban resumption balances the risk of thrombotic events against the risk of gastrointestinal bleeding, as suggested by the guidelines 1.

From the Research

Resuming Apixaban After Diverticulitis Flare

• The patient has been on ceftriaxone/flagyl for a diverticulitis flare and has had apixaban held during the admission 2.
• To resume apixaban safely from home, it is essential to consider the risk of bleeding, which is a significant adverse event associated with anticoagulants like apixaban 2, 3.
• Studies have identified risk factors for bleeding in patients taking apixaban, including age above 74 years, low body mass index (BMI), and low hemoglobin levels 3.
• Anemia has also been associated with an increased risk of bleeding and mortality in patients with atrial fibrillation taking apixaban 4.
• However, the benefits of apixaban in preventing stroke and systemic embolism are consistent in patients with and without anemia 4.
• In patients with acute kidney injury, apixaban use may result in a higher incidence of major bleeding, and concomitant antiplatelet use can increase the risk of bleeding 5.
• To minimize the risk of bleeding when resuming apixaban, it is crucial to monitor the patient's hemoglobin levels, kidney function, and other risk factors for bleeding 3, 4, 5.
• The patient's stable hemoglobin levels over the past six days suggest that resuming apixaban may be safe, but close monitoring and follow-up are necessary to minimize the risk of bleeding 2.