Can I discontinue Aspirin (ASA) 81mg and continue Eliquis (Apixaban) 2.5mg for Deep Vein Thrombosis (DVT) prophylaxis in a post-operative patient with a hemoglobin level of 7.8 g/dL?

Management of Anticoagulation with Low Hemoglobin After Femur Repair

You should discontinue ASA 81mg and continue Eliquis 2.5mg for DVT prophylaxis in a post-operative femur repair patient with a hemoglobin of 7.8 g/dL. 1

Rationale for Discontinuing ASA 81mg

When managing a post-operative orthopedic patient with a hemoglobin of 7.8 g/dL, bleeding risk becomes a significant concern. The American College of Chest Physicians (ACCP) guidelines provide clear direction for managing antithrombotic therapy in the perioperative setting:

1. Low hemoglobin indicates active or recent bleeding: A hemoglobin of 7.8 g/dL in a post-operative patient suggests significant blood loss, which warrants reassessment of antiplatelet therapy.

2. Aspirin increases bleeding risk: For patients at low risk for cardiovascular events, the ACCP suggests stopping ASA 7-10 days before surgery rather than continuing it (Grade 2C) 1. By extension, in a post-operative patient with evidence of significant blood loss, discontinuing ASA is reasonable.

3. Bleeding management priority: The 2020 ACC Expert Consensus recommends temporarily discontinuing oral anticoagulants in patients with nonmajor bleeding until the patient is clinically stable and hemostasis has been achieved 1.

Rationale for Continuing Eliquis 2.5mg

Despite discontinuing ASA, DVT prophylaxis remains essential after femur repair:

1. Appropriate prophylactic dosing: Eliquis (apixaban) 2.5mg twice daily is the FDA-approved dose for DVT prophylaxis following orthopedic surgery 2.

2. Continued need for thromboprophylaxis: The ACCP guidelines recommend that all patients undergoing major orthopedic surgery receive prophylaxis with a pharmacologic agent for a minimum of 10-14 days, with suggested extension up to 35 days 1.

3. Efficacy of Eliquis for DVT prevention: Research demonstrates that apixaban is effective in preventing DVT after orthopedic surgery, with one study showing a lower incidence of DVT compared to LMWH (5.5% vs. 20.0%) 3.

Management Algorithm

1. Immediately discontinue ASA 81mg

   • This reduces the combined anticoagulant/antiplatelet effect and may help stabilize hemoglobin levels

2. Continue Eliquis 2.5mg twice daily

   • Maintain the prophylactic dose as prescribed for DVT prevention
   • No dose adjustment needed for this indication

3. Monitor hemoglobin levels

   • Check hemoglobin in 24-48 hours to ensure stabilization
   • If hemoglobin continues to drop or falls below 7.0 g/dL, consider temporary interruption of Eliquis

4. Watch for signs of bleeding

   • Monitor for overt bleeding, expanding hematoma, or hemodynamic instability
   • If major bleeding occurs, consider reversal strategies with andexanet alfa 1

Special Considerations

• Timing of Eliquis interruption if needed: If bleeding worsens and Eliquis needs to be temporarily stopped, discontinue at least 24 hours before any potential invasive procedures with low bleeding risk, or 48 hours before procedures with moderate to high bleeding risk 2.

• Resumption of Eliquis: If interrupted, restart Eliquis as soon as adequate hemostasis has been established 2.

• Transfusion threshold: Current evidence suggests that transfusion at a hemoglobin threshold of 7.0 g/dL is not associated with improved organ dysfunction compared to no transfusion, supporting a restrictive transfusion strategy 4.

• Duration of prophylaxis: Continue Eliquis for the recommended duration based on the type of surgery (typically 35 days for hip replacement and 12 days for knee replacement) 2.

By discontinuing ASA 81mg while maintaining Eliquis 2.5mg, you can achieve an appropriate balance between bleeding risk and thromboprophylaxis in this post-operative patient with a low hemoglobin level.