How to manage mild rectal bleeding in an elderly patient on Eliquis (apixaban)?

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Last updated: May 23, 2025 • View editorial policy

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From the Guidelines

Mild rectal bleeding in an elderly patient on Eliquis (apixaban) requires prompt medical attention and should not be managed without consulting a healthcare provider, as it can indicate serious conditions and stopping Eliquis without guidance could increase stroke risk. The patient should contact their healthcare provider immediately to report the bleeding, as rectal bleeding while on anticoagulants can be a sign of underlying issues such as hemorrhoids, diverticulosis, or colorectal problems 1.

While awaiting medical advice, the patient should monitor the frequency, amount, and associated symptoms of the bleeding. If external bleeding is visible, gentle pressure with clean gauze or cloth can be applied. It is crucial to avoid using NSAIDs like ibuprofen or aspirin, which can increase the bleeding risk, especially in elderly patients who may already be at a higher risk of gastrointestinal bleeding due to their age and anticoagulant use 1.

To manage constipation, which can exacerbate rectal bleeding, the patient can use stool softeners like docusate sodium (100-300 mg daily), and it is essential to stay hydrated to prevent straining during bowel movements. The healthcare provider may need to adjust the Eliquis dosage, temporarily discontinue it, or investigate the underlying causes of the bleeding. Given the potential for significant bleeding complications in elderly patients on anticoagulants, as highlighted by the increased risk of gastrointestinal bleeding with DOACs like apixaban in patients ≥75 years with AF or VTE 1, careful evaluation and management are necessary to balance the risk of bleeding against the risk of stroke.

In terms of preventive measures, proton pump inhibitors may be considered to reduce the risk of GI bleeding in patients on antithrombotic therapy, especially those at increased risk such as the elderly 1. However, the decision to use these should be made in consultation with a healthcare provider, considering the individual patient's risk factors and the potential interactions with other medications.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Mild Rectal Bleeding in Elderly Patients on Eliquis

  • The management of mild rectal bleeding in elderly patients on Eliquis (apixaban) requires careful consideration of the risks and benefits of anticoagulation therapy 2.
  • A study published in 2024 found that among patients on direct oral anticoagulants (DOACs), 39% were restarted on discharge, 23% were switched to warfarin, and another 23% were not restarted after an episode of rectal bleeding 2.
  • The decision to restart anticoagulation therapy should be individualized, taking into account the patient's underlying condition, the severity of the bleeding, and the risk of thromboembolic events 2, 3.
  • Apixaban has been associated with a lower risk of post-polypectomy bleeding (PPB) and thromboembolic events compared to warfarin, dabigatran, and rivaroxaban, particularly in older patients with right-sided polyps 3.
  • However, bleeding is still a potential adverse event in patients taking apixaban, and prolonged use increases the risk of bleeding 4.

Risk Factors for Gastrointestinal Bleeding

  • Gastrointestinal bleeding (GIB) is a major problem in patients on oral anticoagulation therapy, and the risk is increased with the use of direct oral anticoagulants (DOACs) such as dabigatran and rivaroxaban 5.
  • The risk of GIB is also increased in elderly patients, particularly those with colonic diverticular bleeding and angiodysplasia 5, 6.
  • Other risk factors for GIB include the use of antiplatelet agents, such as acetylsalicylic acid, and the presence of underlying conditions, such as atrial fibrillation and previous strokes 6, 2.

Prevention Strategies

  • Prevention strategies to lower the risk of GIB in patients on anticoagulation therapy include the use of proton pump inhibitors and the avoidance of non-steroidal anti-inflammatory drugs (NSAIDs) 5.
  • Close monitoring of patients on anticoagulation therapy, particularly those at high risk of GIB, is also essential to prevent and manage bleeding complications 6, 2.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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