When to resume Eliquis (apixaban) in an elderly patient with a history of atrial flutter who has developed a spontaneous rectus sheath hematoma without trauma?

From the Guidelines

The decision to resume Eliquis (apixaban) in an elderly patient with atrial flutter who has developed a spontaneous rectus sheath hematoma should typically be delayed until the hematoma has stabilized and there is evidence of hemostasis, usually after 1-2 weeks, as suggested by the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1.

Key Considerations

• Initially, the anticoagulant should be held to prevent further bleeding.
• Before restarting, the patient should undergo clinical reassessment including:
  • Vital signs stability
  • Hemoglobin stabilization
  • Imaging confirmation that the hematoma is not expanding
• The risk of thromboembolism from atrial flutter must be balanced against the risk of recurrent bleeding.

Restarting Anticoagulation

• When restarting, consider using a reduced dose of apixaban (2.5 mg twice daily instead of 5 mg twice daily) for 1-2 weeks before returning to the standard dose.
• Patients should be monitored closely during this transition period with regular clinical evaluations.

Individualized Decision

• The decision should be individualized based on the patient's:
  • CHA₂DS₂-VASc score (stroke risk)
  • HAS-BLED score (bleeding risk)
  • Renal function
  • Age
  • Comorbidities
• In very high-risk patients for thromboembolism, bridging with low molecular weight heparin might be considered before resuming the oral anticoagulant, as it has a shorter half-life and can be discontinued quickly if bleeding recurs, as per the guidelines for the management of atrial fibrillation 1.

From the FDA Drug Label

Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

The decision to resume Eliquis (apixaban) in an elderly patient with a history of atrial flutter who has developed a spontaneous rectus sheath hematoma without trauma should be based on the assessment of adequate hemostasis.

• There is no specific guidance in the drug label on when to resume apixaban after a spontaneous rectus sheath hematoma.
• The label recommends restarting apixaban after surgical or other procedures as soon as adequate hemostasis has been established 2.
• Given the lack of direct information, a conservative approach would be to wait until the hematoma is stable and hemostasis is secure before resuming anticoagulation with apixaban.
• It is crucial to weigh the risks and benefits of anticoagulant therapy in this patient, considering the risk of recurrent atrial flutter and thromboembolic events against the risk of further bleeding complications.
• Close monitoring of the patient's condition and hematoma status is necessary to determine the optimal time to resume apixaban therapy.

From the Research

Resuming Eliquis in Elderly Patients with Atrial Flutter and Spontaneous Rectus Sheath Hematoma

• The decision to resume Eliquis (apixaban) in an elderly patient with a history of atrial flutter who has developed a spontaneous rectus sheath hematoma without trauma should be based on the individual patient's risk of thromboembolism and the risk of anticoagulant-related bleeding 3, 4.
• Studies have shown that patients with chronic atrial flutter are at an increased risk of thromboembolic events, and anticoagulation therapy may decrease this risk 3, 4.
• In the context of spontaneous rectus sheath hematoma, the timing of anticoagulation resumption is crucial. A study found that the majority of patients with spontaneous rectus sheath hematomas can be safely restarted on anticoagulation by day 4 after diagnosis, with a median re-initiation time of 4 days 5.
• Another study suggests that rectus sheath hematoma is not a contraindication to resuming anticoagulation once the hematoma has been adequately managed and the patient has returned to a stable clinical baseline 6.
• It is essential to weigh the risks and benefits of anticoagulation resumption in each patient, considering factors such as the size and stability of the hematoma, the patient's overall clinical condition, and the risk of thromboembolic events 5, 6.
• In the case of an 86-year-old patient with a history of atrial flutter and a spontaneous rectus sheath hematoma of 12 cm without trauma, the decision to resume Eliquis should be made on an individual basis, taking into account the patient's specific clinical characteristics and the potential risks and benefits of anticoagulation therapy 3, 4, 5, 6.