Is it okay to continue Eliquis (apixaban) in a patient with a fall and head strike, despite negative scans?

From the Guidelines

Temporarily stopping Eliquis (apixaban) is generally recommended in a patient with a fall and head strike, even with negative initial scans, to monitor for delayed intracranial hemorrhage. The decision to hold or resume anticoagulation should be individualized based on the patient's bleeding risk versus thrombotic risk, as outlined in the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1. For most patients, a brief 24-48 hour hold of Eliquis is reasonable to monitor for delayed intracranial hemorrhage, which can develop even after negative initial imaging 1. After this observation period with no evidence of bleeding, Eliquis can typically be safely resumed. During the hold period, the patient should be monitored closely for neurological changes such as headache, confusion, weakness, or vomiting that might indicate developing hemorrhage. The timing of medication resumption should consider both the patient's indication for anticoagulation (such as atrial fibrillation or venous thromboembolism) and their risk factors for bleeding, as suggested by the 2020 ACC expert consensus decision pathway 1. In high thrombotic risk patients, a shorter hold or bridging therapy might be considered, as discussed in the management of nonmajor bleeds in patients on oral anticoagulants 1. This cautious approach balances the risk of delayed bleeding against the risk of thrombotic events from prolonged anticoagulant interruption. Key factors to consider in the decision-making process include the patient's clinical presentation, the severity of the head injury, and the presence of any comorbidities that may increase the risk of bleeding or thrombosis, as highlighted in the clinical policy on critical issues in the management of adult patients presenting to the emergency department with mild traumatic brain injury 1. Ultimately, the decision to hold or resume anticoagulation should be made on a case-by-case basis, taking into account the individual patient's unique circumstances and risk profile.

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 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.

The patient had a fall and head strike, but scans were negative. However, the risk of bleeding with apixaban is a concern.

• Bleeding risk: The drug label warns about the increased risk of bleeding with apixaban, which can be serious and potentially fatal.
• Continuation of apixaban: There is no direct information in the label that addresses the specific situation of a patient with a fall and head strike, despite negative scans. It is prudent to exercise caution and consider the potential risks and benefits of continuing apixaban in this patient. Given the information provided and the potential risk of bleeding, it would be recommended to consult with a healthcare professional to determine the best course of action for this patient 2.

From the Research

Patient Considerations

• The decision to continue Eliquis (apixaban) in a patient with a fall and head strike, despite negative scans, should be based on individual patient factors and the risk of stroke or systemic embolism versus the risk of bleeding.
• Studies have shown that apixaban is effective in reducing the risk of stroke or systemic embolism in patients with nonvalvular atrial fibrillation, with a lower risk of major bleeding compared to warfarin 3, 4.
• The ARISTOTLE trial found that apixaban was associated with a lower risk of intracranial hemorrhage compared to warfarin, which may be relevant in patients with a history of falls 3.

Bleeding Risk

• Patients with a history of falls may be at higher risk of major bleeding, including intracranial bleeding, when taking anticoagulants such as apixaban or warfarin 5.
• However, the ARISTOTLE trial found that the efficacy and safety of apixaban compared to warfarin were consistent, regardless of history of falling 5.
• A study published in the American Journal of Medicine found that patients with atrial fibrillation and a history of falling had higher rates of major bleeding, including intracranial bleeding, but similar rates of stroke or systemic embolism 5.

Valvular Heart Disease

• Apixaban has been studied in patients with valvular heart disease, and the results suggest that it is effective in reducing the risk of stroke or systemic embolism, with a similar safety profile to warfarin 6.
• However, the presence of valvular heart disease may increase the risk of bleeding, and this should be taken into account when making decisions about anticoagulation therapy 6.

Clinical Decision-Making

• The decision to continue apixaban in a patient with a fall and head strike, despite negative scans, should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• Clinicians should weigh the benefits of anticoagulation therapy against the risks of bleeding, and consider alternative treatments or dose adjustments as needed 3, 5.