How soon after an ischemic cerebrovascular accident (CVA) can Eliquis (apixaban) be resumed?

From the Guidelines

Eliquis (apixaban) can typically be resumed between 2 and 14 days after an ischemic CVA, with the exact timing depending on the risk of hemorrhagic transformation and individual patient factors. The decision to resume anticoagulation therapy, such as Eliquis, after an ischemic cerebrovascular accident (CVA) is crucial and must balance the risk of recurrent thromboembolism against the risk of hemorrhagic transformation of the infarct 1.

Key Considerations

• The risk of hemorrhagic transformation is a significant concern in the early days following an ischemic stroke, and this risk must be weighed against the benefits of anticoagulation.
• For patients with a history of cardiovascular disease (CVD), including those with atrial fibrillation or venous thromboembolism, the use of a direct oral anticoagulant (DOAC) like Eliquis is preferred when anticoagulant therapy is indicated 1.
• The timing of resuming Eliquis can vary based on the severity of the stroke and individual patient factors, such as blood pressure control and the presence of other risk factors for bleeding or thromboembolism.

Resumption Guidelines

• For minor strokes, resumption of Eliquis may occur as early as 3-5 days after the event, provided there is no evidence of hemorrhagic transformation on neuroimaging.
• Moderate strokes may require waiting 5-7 days before resuming Eliquis, while severe strokes may necessitate waiting 14 days or longer.
• Close monitoring for any signs of neurological deterioration or bleeding is essential after resuming Eliquis.

Dosing and Monitoring

• The standard dosing of Eliquis (5 mg twice daily, or 2.5 mg twice daily for patients meeting dose-reduction criteria) should be used when restarting therapy.
• Regular follow-up with a healthcare provider is necessary to assess the patient's response to therapy and adjust the treatment plan as needed. The approach to resuming Eliquis after an ischemic CVA must be individualized, taking into account the specific circumstances of each patient and the latest clinical guidelines 1.

From the Research

Resuming Eliquis after Ischemic CVA

• The optimal time to resume Eliquis (apixaban) after an ischemic cerebrovascular accident (CVA) is uncertain, but studies suggest that early initiation may be beneficial in certain cases 2, 3, 4.
• A study published in 2020 found that direct oral anticoagulant initiation within 2 days of an acute ischemic stroke is associated with a 5% rate of hemorrhagic transformation, and that infarct size and presence of hemorrhage are important factors in identifying the optimal time to initiation 2.
• Another study published in 2024 found that early initiation of apixaban, tailored to infarct size, could serve as a viable strategy to enhance functional outcomes, and may potentially decrease stroke progression and early recurrence without elevating the risk of symptomatic hemorrhagic transformation 3.
• The AREST trial, published in 2021, compared early anticoagulation with apixaban in AF patients with stroke or transient ischemic attack (TIA) versus warfarin administration at later intervals, and found that apixaban had statistically similar yet generally numerically lower rates of recurrent strokes/TIA, death, and symptomatic hemorrhages 4.
• The decision to resume Eliquis after an ischemic CVA should be made on a case-by-case basis, taking into account the individual patient's risk factors, infarct size, and presence of hemorrhage, as well as the potential benefits and risks of early anticoagulation 2, 3, 4.

Considerations for Resuming Eliquis

• Infarct size is an important factor in determining the optimal time to resume Eliquis, with smaller infarcts potentially allowing for earlier initiation 3, 4.
• The presence of hemorrhage or cerebral microbleeds may increase the risk of hemorrhagic transformation, and should be taken into account when deciding when to resume Eliquis 2.
• The patient's overall clinical condition, including their risk of recurrent stroke and bleeding, should be carefully considered when making decisions about resuming Eliquis 2, 3, 4.