From the FDA Drug Label
Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.
The patient has a tiny focus of hemorrhage along the right temporal lobe, which may be subdural or subarachnoid, but there is no substantial mass effect.
- The decision to repeat the CT head in 24 hours should be based on the patient's clinical condition and the presence of any new or worsening symptoms.
- It is not explicitly stated in the label when it is safe to resume apixaban for a patient with a fib who has experienced a hemorrhage, but apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established 1.
From the Research
Yes, a repeat CT head scan should be performed in 24 hours for this patient with dementia on apixaban who has experienced falls and has a small temporal lobe hemorrhage. This follow-up imaging is essential to monitor for potential expansion of the hemorrhage. Regarding anticoagulation, apixaban should be temporarily discontinued until hemorrhage stability is confirmed. Generally, it is safe to resume apixaban after 14-30 days following intracranial hemorrhage, but this timeframe should be individualized based on the patient's specific risk factors, as seen in studies such as 2. The decision to restart anticoagulation requires balancing the risk of stroke from atrial fibrillation against the risk of recurrent bleeding. Factors to consider include the size and stability of the hemorrhage, the patient's fall risk, blood pressure control, and the indication for anticoagulation. A neurology or cardiology consultation may be beneficial for this complex decision, as they can provide guidance on managing bleeding complications associated with apixaban, as reported in cases such as 3. While the anticoagulant is held, close monitoring for thromboembolic events is necessary. When apixaban is eventually restarted, measures to reduce fall risk should be implemented, including physical therapy evaluation, environmental modifications in the nursing home, and possibly medication review to minimize medications that increase fall risk. It's also important to note that apixaban has been shown to have a lower risk of major bleeding compared to warfarin, as seen in the ARISTOTLE trial 2, but the management of bleeding complications is crucial to prevent adverse outcomes. In addition, the use of 3-factor prothrombin complex concentrate (PCC3) has been reported to be effective in managing apixaban-associated intracranial bleeding, as seen in cases such as 3.
Some key points to consider in the management of this patient include:
- Close monitoring of the patient's neurological status, as described in 4
- Regular assessment of the patient's fall risk and implementation of measures to reduce this risk
- Collaboration with neurology and cardiology specialists to determine the best course of action for anticoagulation therapy
- Consideration of the use of PCC3 in the management of apixaban-associated bleeding complications, as reported in 3
- Review of the patient's medication list to minimize the use of medications that may increase the risk of bleeding or falls.