What is the follow-up plan for a 76-year-old male with Benign Prostatic Hyperplasia (BPH) who was seen in the Emergency Room (ER) and had a Foley catheter placed, takes Eliquis (apixaban) for Atrial Fibrillation (A-fib) and has experienced epistaxis?

From the Guidelines

For a 76-year-old male with BPH who had a Foley catheter placed in the ER and is taking Eliquis (apixaban) for atrial fibrillation with a history of epistaxis, I recommend a urological evaluation for definitive BPH management while carefully balancing his anticoagulation needs. The patient should continue Eliquis as prescribed unless specifically directed otherwise by his cardiologist, as stopping anticoagulation increases stroke risk 1. For BPH management, consider alpha-blockers like tamsulosin 0.4mg daily or alfuzosin 10mg daily to relax prostate smooth muscle and improve urination, as well as 5-alpha reductase inhibitors such as finasteride 5mg daily for prostate size reduction in long-term management 1. The Foley catheter should be removed after starting alpha-blocker therapy (typically 2-3 days), followed by a trial of voiding. For epistaxis related to Eliquis, recommend nasal saline sprays, humidification, and avoiding nose picking. If urinary retention recurs after catheter removal or if hematuria develops, prompt urological reevaluation is necessary. The patient may ultimately need procedures like TURP or other minimally invasive options if medical management fails, but these require careful perioperative anticoagulation management given his atrial fibrillation. In the event of severe bleeding, andexanet alfa may be considered for reversal of anticoagulation, as it has been shown to decrease anti-FXa activity by 92% for both apixaban and rivaroxaban, with excellent or good hemostasis 12 hours after infusion 1. However, the use of andexanet alfa should be carefully weighed against the risk of thrombotic events, and its administration should be guided by a thorough evaluation of the patient's individual risk factors and clinical presentation. Ultimately, a multidisciplinary approach involving urology, cardiology, and other relevant specialties is essential to optimize the patient's management and minimize the risk of adverse outcomes.

Some key considerations for the patient's management include:

• Careful balancing of anticoagulation needs with the risk of bleeding complications
• Close monitoring for signs of urinary retention, hematuria, or other complications
• Prompt evaluation and treatment of any bleeding episodes, including the use of andexanet alfa if necessary
• Consideration of alternative anticoagulation strategies or dose adjustments if the patient experiences recurrent bleeding episodes
• A comprehensive treatment plan that addresses the patient's BPH, atrial fibrillation, and other comorbid conditions.

By prioritizing the patient's morbidity, mortality, and quality of life, and carefully weighing the potential benefits and risks of different management strategies, it is possible to develop an effective and individualized treatment plan that meets the patient's unique needs and minimizes the risk of adverse outcomes.

From the FDA Drug Label

If apixaban tablets are discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant [see Dosage and Administration (2.4) and Clinical Studies (14.1)]. 5.2 Bleeding Apixaban tablets increases the risk of bleeding and can cause serious, potentially fatal, bleeding Concomitant use of drugs affecting hemostasis increases the risk of bleeding. These include aspirin and other antiplatelet agents, other anticoagulants, heparin, thrombolytic agents, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs)

The patient is taking apixaban for A-fib and has had bloody noses. Given the patient's history of bleeding and the fact that apixaban increases the risk of bleeding, it is essential to monitor the patient closely for signs and symptoms of blood loss.

• The patient should be advised to report any signs and symptoms of blood loss immediately or go to an emergency room.
• Consider coverage with another anticoagulant if apixaban is discontinued for any reason other than pathological bleeding or completion of a course of therapy 2.
• The concomitant use of drugs affecting hemostasis, such as aspirin and other antiplatelet agents, should be avoided or used with caution to minimize the risk of bleeding 2.

From the Research

Patient Profile

• 76-year-old male with Benign Prostatic Hyperplasia (BPH)
• Recently seen in the ER and had a Foley catheter placed
• Taking apixaban (Elequis) for Atrial Fibrillation (A-fib)
• Experiencing bloody noses

Management of Bleeding

• The patient's bleeding can be challenging to manage due to his anticoagulation therapy 3, 4
• Tranexamic acid (TXA) has been used to treat acute bleeding in various settings, including epistaxis (nosebleeds) 5
• For patients taking direct oral anticoagulants (DOACs) like apixaban, specific reversal agents such as andexanet alfa are available to reverse anticoagulation effects in cases of life-threatening or uncontrolled bleeding 4
• Nonspecific strategies, including supplementation of clotting factors with prothrombin complex concentrates (PCCs), may also be considered 4

Anticoagulation Therapy

• Apixaban is a selective factor Xa inhibitor, approved for use in the prevention of stroke in patients with nonvalvular atrial fibrillation and in the prevention and treatment of acute venous thromboembolism (VTE) 6
• The decision to restart anticoagulation therapy after gastrointestinal bleeding (GIB) should be made on a case-by-case basis, considering the risk of thromboembolism and the risk of recurrent bleeding 7
• Resuming anticoagulation therapy between 7 and 14 days after GIB may be considered, and apixaban may be a preferred option when restarting a DOAC therapy due to its lower risk of GIB compared to other DOACs 7