Is Eliquis (apixaban) safe to use in a patient with a history of brain bleed?

From the Guidelines

Eliquis (apixaban) is generally not recommended for patients with a history of brain bleeds due to the increased risk of recurrent hemorrhage. This medication is an anticoagulant that inhibits blood clotting, which can exacerbate bleeding risks in patients with prior intracranial hemorrhage. The decision to use Eliquis in such patients requires careful individualized risk assessment, weighing the potential benefits of preventing thrombotic events against the heightened risk of recurrent bleeding.

Key Considerations

• The timing since the brain bleed,
• the cause of the original hemorrhage,
• whether the underlying cause has been addressed, and
• the patient's overall bleeding risk profile are critical factors in this decision.

Alternative Approaches

If anticoagulation is absolutely necessary, such as in patients with high-risk atrial fibrillation or recurrent venous thromboembolism, alternative approaches might be considered, including:

• left atrial appendage closure devices for atrial fibrillation patients
• possibly lower doses of anticoagulants with close monitoring. This complex risk-benefit assessment should be made by a multidisciplinary team including neurology, cardiology, and hematology specialists, with the patient fully informed about the potential risks 1. According to the 2020 ACC expert consensus decision pathway, for patients with a history of cerebrovascular disease, the antithrombotic therapy used will depend upon the type of cerebrovascular disease, prior symptomatic events, prior interventions, and perceived bleeding risk 1. Additionally, the 2018 Chest guideline suggests using apixaban, edoxaban, or dabigatran 110 mg in patients with prior unprovoked bleeding, warfarin-associated bleeding, or at high risk of bleeding, as they demonstrate significantly less major bleeding compared with warfarin 1.

From the FDA Drug Label

WARNINGS AND PRECAUTIONS Apixaban can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. The FDA drug label does not answer the question.

From the Research

Safety of Eliquis in Patients with a History of Brain Bleed

• The use of Eliquis (apixaban) in patients with a history of brain bleed is a concern due to the risk of recurrent bleeding 2, 3.
• Studies have shown that apixaban is associated with a lower rate of intracranial hemorrhages compared to warfarin 2, 4.
• A study published in 2020 found that apixaban offers several advantages over historical therapy for the treatment and secondary prevention of venous thromboembolism, but there is a dearth of data on patients with a history of brain bleed 5.
• A 2023 study found that apixaban was associated with a lower risk of recurrent venous thromboembolism and major bleeding compared to warfarin in patients with venous thromboembolism, including those with a history of bleed 3.
• Another study published in 2025 found that apixaban reduced the risk of stroke or systemic embolism in patients with subclinical atrial fibrillation and a history of stroke or transient ischemic attack, but increased the risk of major bleeding 6.
• A 2021 study found that patients on warfarin were at increased risk of acute intracranial hemorrhage compared to those on direct oral anticoagulants, including apixaban 4.

Key Findings

• Apixaban may be a safer alternative to warfarin in patients with a history of brain bleed due to its lower risk of intracranial hemorrhages 2, 4.
• However, the use of apixaban in patients with a history of brain bleed should be carefully considered, taking into account the individual patient's risk factors and medical history 5, 3, 6.
• Further studies are needed to fully understand the safety and efficacy of apixaban in patients with a history of brain bleed 5, 3, 6.