How to manage a brain bleed in a patient on Eliquis (apixaban)?

Management of Brain Bleed in a Patient on Eliquis (Apixaban)

For patients with intracranial hemorrhage while on apixaban, immediately stop the anticoagulant, administer andexanet alfa as the specific reversal agent, and provide supportive care while monitoring for neurological deterioration. 1

Initial Assessment and Management

Immediate Steps:

• Stop apixaban immediately
• Assess hemodynamic stability and neurological status
• Obtain urgent CT scan to determine hemorrhage location and size
• Classify the bleed as a critical site hemorrhage (intracranial hemorrhage is always considered major bleeding)

Reversal Strategy:

1. Administer andexanet alfa as the specific reversal agent for apixaban 1:

   • Low dose (400 mg IV bolus followed by 4 mg/min infusion for up to 120 minutes) if:
     • Last apixaban dose was ≥8 hours prior, OR
     • Last dose of apixaban ≤5 mg was taken <8 hours prior
   • High dose (800 mg IV bolus followed by 8 mg/min infusion for up to 120 minutes) if:
     • Last dose of apixaban >5 mg was taken <8 hours prior, OR
     • Unknown dose was taken <8 hours prior

2. If andexanet alfa is unavailable, use prothrombin complex concentrate (PCC) 1

3. For recent ingestion (within 2-4 hours), consider activated charcoal to reduce absorption 1, 2

Supportive Care Measures

• Provide volume resuscitation if needed
• Consider neurosurgical consultation for possible intervention
• Monitor for neurological deterioration with serial neurological exams
• Manage blood pressure (target SBP <160 mmHg to prevent hematoma expansion)
• Correct other coagulopathies (thrombocytopenia, uremia, liver disease)
• Discontinue any antiplatelet agents 1

Monitoring

• Repeat head CT at 6-24 hours to assess for hemorrhage expansion
• Monitor for signs of increased intracranial pressure
• Standard laboratory monitoring including CBC, renal function, and coagulation studies
• Note that routine coagulation tests (PT, INR, aPTT) are not reliable for monitoring apixaban activity 2

Important Considerations

Restart Anticoagulation Decision

After stabilization, carefully evaluate whether to restart anticoagulation based on:

• Indication for anticoagulation (stroke risk vs. bleeding risk)
• Source and size of the bleed
• Patient's risk of thromboembolism

For intracranial hemorrhage, anticoagulation should typically be delayed for at least 4 weeks due to high risk of rebleeding 1

Common Pitfalls to Avoid

1. Delayed recognition and reversal - Brain bleeds require immediate action; each hour of delay increases mortality
2. Inadequate reversal - Using inappropriate doses or agents for reversal
3. Premature restart of anticoagulation - Restarting too soon can lead to rebleeding
4. Failure to address modifiable risk factors - Uncontrolled hypertension, antiplatelet use
5. Overlooking the need for specific reversal agents - Andexanet alfa is specifically designed for factor Xa inhibitors like apixaban 1, 2

Special Considerations

• Hemodialysis does not effectively remove apixaban due to high protein binding 2
• The anticoagulant effect of apixaban persists for approximately 24 hours after the last dose 2
• Vitamin K administration is ineffective for apixaban reversal 2
• Patients with brain bleeds on apixaban have better outcomes when treated with specific reversal agents compared to general hemostatic agents 3, 4

Remember that intracranial hemorrhage while on anticoagulation carries significant mortality risk, and prompt, decisive action is essential for improving patient outcomes.