What to do with a 75-year-old male patient with atrial flutter on Eliquis (apixaban) who has a history of gastrointestinal (GI) bleeds and now presents with a decrease in hemoglobin (Hb) and hematocrit (Hct)?

From the Guidelines

Immediate discontinuation of Eliquis (apixaban) is recommended for this 75-year-old male patient with atrial flutter and a history of gastrointestinal (GI) bleeds, given his current presentation with decreased hemoglobin (Hb) and hematocrit (Hct) levels. The patient's history of GI bleeds and current decrease in Hb and Hct levels, from 12 and 35 to 10.8 and 32.1, respectively, indicate a potential recurrence of bleeding, which is a critical concern in patients on anticoagulation therapy 1. Given the patient's age and medical history, the risk of recurrent GI bleeding must be carefully weighed against the risk of thromboembolism from atrial flutter. The decision to restart anticoagulation should be based on a thorough risk-benefit analysis, considering the patient's CHA₂DS₂-VASc score and HAS-BLED score, as well as the potential benefits and risks of alternative stroke prevention strategies, such as left atrial appendage closure devices or other anticoagulants with potentially lower GI bleeding risk 1. Key steps in managing this patient include:

• Admitting the patient for close monitoring and stabilization
• Assessing hemodynamic stability and obtaining complete blood counts, coagulation studies, and type and cross-matching for potential blood transfusion
• Administering blood products if the patient is actively bleeding or hemodynamically unstable
• Consulting gastroenterology for endoscopic evaluation to identify and potentially treat the bleeding source
• Considering the use of reversal agents, such as andexanet alfa, for life-threatening hemorrhage on direct oral anticoagulants, as recommended by guidelines 1. Ultimately, the goal is to balance the competing risks of thromboembolism and recurrent GI bleeding, prioritizing the patient's morbidity, mortality, and quality of life.

From the FDA Drug Label

Apixaban tablets increases the risk of bleeding and can cause serious, potentially fatal, bleeding [see Dosage and Administration (2. Apixaban can cause bleeding which can be serious and rarely may lead to death. You may have a higher risk of bleeding if you take apixaban tablets and take other medicines that increase your risk of bleeding, including: aspirin or aspirin-containing products long-term (chronic) use of nonsteroidal anti-inflammatory drugs (NSAIDs) warfarin sodium (COUMADIN®, JANTOVEN®) any medicine that contains heparin selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) other medicines to help prevent or treat blood clots

The patient has a history of GI bleeds and is currently on apixaban with a decrease in hemoglobin (Hb) and hematocrit (Hct). Given the patient's history of bleeding and the current decrease in Hb and Hct, it is essential to closely monitor the patient's condition and adjust the apixaban dose as needed to minimize the risk of further bleeding.

• The patient should be advised to report any unusual bleeding to their physician immediately.
• The physician should consider reducing the dose of apixaban or discontinuing it if the patient experiences any significant bleeding.
• The patient's renal function and liver function should also be closely monitored, as apixaban is metabolized by the liver and excreted by the kidneys.
• It is crucial to weigh the benefits and risks of continuing apixaban in this patient, considering their history of GI bleeds and current decrease in Hb and Hct. 2 2 2

From the Research

Patient Management

The patient is a 75-year-old male with atrial flutter on Eliquis (apixaban) who has a history of gastrointestinal (GI) bleeds and now presents with a decrease in hemoglobin (Hb) and hematocrit (Hct) levels.

• The patient's Hb and Hct levels have decreased to 10.8 and 32.1, respectively, from previous levels of 12 and 35.
• The patient has a history of GI bleeds and is on anticoagulant therapy with Eliquis.

Considerations for Anticoagulant Therapy

• A study published in 2018 found that the incidence of hospitalization for upper gastrointestinal tract bleeding was lower for patients prescribed apixaban compared to those prescribed rivaroxaban, dabigatran, or warfarin 3.
• Another study published in 2021 found that apixaban had a lower rate of major gastrointestinal bleeding compared to dabigatran and rivaroxaban 4.
• However, the patient's history of GI bleeds and current decrease in Hb and Hct levels suggest a need for careful consideration of the risks and benefits of continuing anticoagulant therapy.

Management of Anemia and Bleeding Risk

• A study published in 2018 found that anemic patients with cancer or without cancer had a higher risk of major bleeding during anticoagulant therapy for venous thromboembolism compared to those without anemia 5.
• The study suggested that anemia independently predicted the risk for major bleeding in patients with and without cancer.
• Another study published in 2019 provided expert consensus recommendations for the management of thrombocytopenic patients with blood cancer and venous thromboembolism, including the use of low molecular weight heparin at therapeutic doses for platelet counts between 50-100 x 10^9/L and at 50% dose reduction for platelet counts between 30-50 x 10^9/L 6.

Next Steps

• Consider the patient's current Hb and Hct levels and history of GI bleeds when deciding on the next course of action.
• Evaluate the patient's overall clinical condition and assess the risk of bleeding versus the risk of thromboembolism.
• Consider consulting with a gastroenterologist or hematologist to determine the best course of action for managing the patient's anemia and bleeding risk.
• Review the patient's medication list and consider the potential for drug interactions or other factors that may be contributing to the patient's anemia and bleeding risk.