What are the implications of stopping Eliquis (apixaban) for atrial fibrillation (AFib) in the setting of a hemothorax?

From the Guidelines

In the setting of a hemothorax, Eliquis (apixaban) should be temporarily discontinued immediately due to the active bleeding complication. This decision is based on the increased bleeding risk associated with anticoagulant use, as highlighted in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. The guideline emphasizes the importance of managing bleeding risks in patients with atrial fibrillation, particularly in the context of anticoagulant therapy.

Key Considerations

• The risk of stroke or noncentral nervous system embolism after elective temporary discontinuation of anticoagulation should be weighed against the risk of bleeding, as noted in the ROCKET AF trial 1.
• The decision to restart Eliquis should be made in consultation with both the treating pulmonologist/thoracic surgeon and cardiologist, typically after the hemothorax has resolved and bleeding risk has stabilized, usually within 1-4 weeks depending on severity.
• During this interruption period, bridging anticoagulation is generally not recommended unless the patient has an extremely high thromboembolic risk, as suggested by the updated guidelines from the French Working Group on Perioperative Hemostasis (GIHP) 1.
• When restarting, the standard dose for atrial fibrillation is typically resumed (5mg twice daily or 2.5mg twice daily for patients meeting dose reduction criteria), as outlined in the ARISTOTLE trial 1.

Monitoring and Follow-up

• Patients should be monitored closely for both bleeding complications and signs of thromboembolism during this period, with careful consideration of the timing of anticoagulation resumption to balance the risk of recurrent bleeding against the risk of thromboembolic events from untreated atrial fibrillation.
• The benefit of apixaban in reducing stroke and systemic embolism risk, as demonstrated in the ARISTOTLE trial 1, should be weighed against the potential risks of bleeding, particularly in the context of a hemothorax.

From the FDA Drug Label

If you are taking apixaban tablets for atrial fibrillation, stopping apixaban tablets may increase your risk of having a stroke. The implications of stopping Eliquis (apixaban) for atrial fibrillation (AFib) in the setting of a hemothorax are not directly addressed in the provided drug labels. However, it is stated that stopping apixaban tablets may increase the risk of having a stroke in patients with atrial fibrillation 2.

• Key consideration: Stopping apixaban may increase the risk of stroke.
• Clinical decision: The decision to stop apixaban in a patient with a hemothorax should be made with caution, considering the potential increased risk of stroke.
• Recommendation: Consult with a healthcare professional to weigh the risks and benefits of stopping apixaban in this setting. 2

From the Research

Implications of Stopping Eliquis (Apixaban) for Atrial Fibrillation (AFib) in the Setting of a Hemothorax

• Stopping apixaban in patients with atrial fibrillation may increase the risk of thromboembolic events, such as stroke or systemic embolism 3, 4
• The risk of bleeding, including major bleeding, is a concern when using anticoagulants like apixaban, especially in patients with a high risk of thrombosis 3, 5, 6, 7
• Apixaban has been shown to have a lower risk of major bleeding compared to warfarin, but the risk is still present 5, 7
• In the setting of a hemothorax, the risk of bleeding may be increased, and stopping apixaban may not be sufficient to prevent further bleeding 6, 7
• The decision to stop apixaban should be made on a case-by-case basis, taking into account the individual patient's risk of thromboembolic events and bleeding 4, 7
• Factors associated with an increased risk of major bleeding on apixaban include older age, prior hemorrhage, prior stroke or transient ischemic attack, diabetes, lower creatinine clearance, decreased hematocrit, aspirin therapy, and nonsteroidal anti-inflammatory drugs 7

Considerations for Managing Bleeding Risk

• Close monitoring of patients for signs of bleeding is essential when using anticoagulants like apixaban 5, 6, 7
• The use of apixaban should be carefully considered in patients with a high risk of bleeding, and alternative treatments may be necessary 3, 4
• In cases of major bleeding, medical or surgical intervention may be necessary, and the patient's antithrombotic therapy may need to be adjusted 5, 7