From the Guidelines
The main risk of reversing Eliquis (apixaban) is an increased risk of blood clots and thrombotic events, with a reported rate of thromboembolic complications ranging from 4% to 10%. Eliquis reversal should only be done in emergency situations like life-threatening bleeding or urgent surgery. The reversal agent for Eliquis is andexanet alfa (Andexxa), given as an IV bolus followed by a 2-hour infusion, with dosing depending on the last Eliquis dose and timing, as recommended in the most recent guidelines 1.
Additional considerations include:
- Monitoring for signs of thrombosis after reversal
- Restarting anticoagulation as soon as medically appropriate to mitigate the risk of thrombosis after anticoagulation reversal 1
- Using prothrombin complex concentrate if andexanet alfa is unavailable
- Administering activated charcoal if Eliquis was ingested within 2-6 hours
Reversing Eliquis removes its anticoagulant effects, leaving the patient vulnerable to clotting, especially if they have underlying risk factors. The abrupt removal of anticoagulation can potentially lead to a rebound hypercoagulable state. Therefore, the decision to reverse should carefully weigh the risks of continued bleeding against the risks of thrombosis, as emphasized in the latest research 1.
It is essential to note that the risk of thromboembolic complications is impacted by the patient's underlying risk of thrombotic complications if anticoagulation therapy is withheld during or after a bleeding episode or after major surgery 1. The most recent study on the topic highlights the importance of restarting anticoagulation as soon as clinically acceptable to mitigate the risk of thrombosis after anticoagulation reversal 1.
From the FDA Drug Label
An agent to reverse the anti-factor Xa activity of apixaban is available
- The risks of reversing Eliquis (apixaban) include potentially fatal bleeding, as apixaban can cause serious bleeding.
- The use of an agent to reverse the anti-factor Xa activity of apixaban is available, but the specific risks associated with its use are not directly stated in the label.
- It is recommended to promptly evaluate signs and symptoms of blood loss when using apixaban or its reversal agent 2.
From the Research
Risks of Reversing Eliquis (Apixaban)
The reversal of apixaban, a direct oral anticoagulant (DOAC), is a complex process that carries several risks. Some of the key risks associated with reversing apixaban include:
- Thromboembolic events: A study published in 2020 found that 3 (8.6%) patients experienced thromboembolic events during hospitalization after receiving activated prothrombin complex concentrates (aPCCs) to reverse apixaban 3.
- Failure to achieve clinical hemostasis: The same study found that 11 patients (31.4%) did not achieve clinical hemostasis, and 7 of these patients died during hospitalization 3.
- Increased risk of bleeding: Concomitant medications that interact with anti-factor Xa inhibitors can increase the risk of bleeding, and 21 (60%) patients in the study were receiving such medications 3.
Reversal Agents
Several reversal agents are available or under development for apixaban, including:
- Andexanet alfa: A specific reversal agent approved for the reversal of rivaroxaban and apixaban in patients with life-threatening or uncontrolled bleeding 4, 5.
- Idarucizumab: A reversal agent approved for the reversal of dabigatran, but not apixaban 4, 5.
- Ciraparantag: A potential "universal" reversal agent under clinical development 4, 5.
- Prothrombin complex concentrates (PCCs): A nonspecific strategy that may be used to reverse apixaban in the absence of a specific reversal agent 6, 5, 7.
Considerations for Reversal
The decision to reverse apixaban should be made on a case-by-case basis, taking into account the individual patient's risk of bleeding and thromboembolic events. The choice of reversal agent and strategy will depend on the specific clinical situation and the availability of reversal agents 3, 5, 7.