What is the appropriate workup for a 90-year-old female with recurrent hematuria, unresponsive to antibiotics, with a history of dementia and atrial fibrillation, on Apixaban (apixaban)?

Workup for Recurrent Hematuria in a 90-Year-Old Female on Apixaban

A comprehensive urologic evaluation is essential for this 90-year-old female with recurrent hematuria unresponsive to antibiotics, with priority consideration for temporarily holding apixaban to facilitate proper assessment and reduce bleeding risk.

Initial Assessment

The workup for recurrent hematuria in this elderly patient on anticoagulation requires a systematic approach:

1. Medication Review

   • Apixaban is a likely contributing factor to the hematuria, especially given the patient's advanced age 1
   • Consider temporary interruption of apixaban for proper evaluation
   • For elective procedures with moderate bleeding risk, apixaban should be discontinued at least 48 hours prior 1

2. Laboratory Testing

   • Complete blood count to assess for anemia
   • Comprehensive metabolic panel to evaluate renal function
   • Urinalysis with microscopy to differentiate glomerular from non-glomerular hematuria
   • Urine culture to rule out persistent infection despite antibiotic treatment
   • Coagulation studies (PT/INR, aPTT)
   • Consider measuring apixaban levels if available (levels >50 ng/mL with serious bleeding may warrant reversal consideration) 2

3. Imaging Studies

   • Renal ultrasound: First-line imaging to evaluate for structural abnormalities, hydronephrosis, masses, or stones
   • Consider CT urography if ultrasound is non-diagnostic and renal function permits

Management Considerations

Anticoagulation Management

• Given the patient's age (≥80 years), she should be on the reduced dose of apixaban 2.5 mg twice daily 2
• For diagnostic procedures with bleeding risk, consider:
  • Temporary interruption of apixaban for 48 hours 1
  • If urgent evaluation is needed with significant bleeding, consider reversal options:
    • Andexanet alfa has shown 92% reduction in anti-FXa activity for apixaban-treated patients 2
    • Four-factor prothrombin complex concentrate (PCC) may be considered if andexanet alfa is unavailable 2

Urologic Evaluation

• Urgent urology referral is warranted given:
  • Age >90 years (high risk for malignancy)
  • Recurrent hematuria despite antibiotics
  • Anticoagulation use

Special Considerations for Elderly Patients with Dementia

• Apixaban has demonstrated better safety profile in patients with dementia compared to other anticoagulants 3
• If anticoagulation must be continued during evaluation, apixaban is preferred over other options for this patient with dementia 3

Potential Diagnoses to Consider

1. Urologic Malignancy - High priority given age and persistent symptoms

   • Bladder cancer
   • Upper tract urothelial carcinoma
   • Renal cell carcinoma

2. Anticoagulant-Related Bleeding - Common in elderly patients on apixaban

   • Consider dose adjustment based on weight and renal function

3. Urinary Tract Infection - Despite antibiotic treatment

   • Consider resistant organisms or inadequate antibiotic course

4. Urolithiasis - Common cause of hematuria in elderly

5. Benign Prostatic Hyperplasia - Not applicable in female patient

Follow-up Plan

• After initial evaluation, coordinate care between cardiology (for atrial fibrillation management) and urology
• If no clear cause is identified after initial workup, consider cystoscopy and upper tract evaluation
• Reassess anticoagulation strategy based on findings and bleeding risk

Pitfalls to Avoid

1. Attributing hematuria solely to anticoagulation - Always rule out underlying pathology, especially malignancy
2. Prolonged interruption of anticoagulation - Increases stroke risk in atrial fibrillation
3. Inadequate evaluation due to age or comorbidities - Advanced age increases malignancy risk, warranting thorough evaluation
4. Failure to adjust apixaban dosing - Patient's age (>80) requires consideration for reduced dosing

Remember that in elderly patients with recurrent hematuria, the risk of urologic malignancy is significant and warrants thorough evaluation, even when on anticoagulation therapy.