Should I hold Eliquis (apixaban) if a hematoma is suspected?

Management of Suspected Hematoma in Patients on Apixaban (Eliquis)

Apixaban (Eliquis) should be held immediately if a hematoma is suspected, as continued anticoagulation could lead to expansion of the hematoma and increased morbidity and mortality.

Assessment of Hematoma

When a hematoma is suspected in a patient on apixaban, the following steps should be taken:

1. Evaluate the hematoma location and severity:

   • Determine if the hematoma is in a critical location (intracranial, spinal, retroperitoneal)
   • Assess for signs of hemodynamic instability or compartment syndrome
   • Evaluate for mass effect or functional impairment

2. Laboratory assessment:

   • Complete blood count to assess for anemia
   • Renal function (as apixaban clearance is affected by renal function)
   • Coagulation parameters (though standard tests may not accurately reflect apixaban activity)

Management Algorithm

Immediate Actions:

1. Hold apixaban immediately regardless of hematoma location 1
2. Monitor for expansion of the hematoma with appropriate imaging

For Life-Threatening Bleeding:

1. Consider reversal with andexanet alfa for apixaban-related life-threatening bleeding, especially with intracranial hemorrhage 2
2. If andexanet alfa is unavailable, administer prothrombin complex concentrate (PCC) at 25-50 U/kg 2

For Non-Life-Threatening Bleeding:

1. Hold apixaban and monitor the hematoma
2. Provide supportive care including local measures to control bleeding if accessible
3. Monitor hemoglobin levels and provide blood products if necessary

Resumption of Anticoagulation

Resumption of apixaban should be considered only when:

1. Adequate hemostasis is established (typically at least 24 hours after the bleeding has stopped) 1
2. The risk of thrombosis outweighs the risk of recurrent bleeding

For patients with high thrombotic risk but ongoing concerns about bleeding:

1. Consider starting with prophylactic doses of heparin or LMWH first
2. Transition back to apixaban when bleeding risk is acceptably low 1

Special Considerations

Renal Function

• Apixaban has prolonged clearance in patients with renal impairment:
  • Normal/mild impairment (CrCl ≥50 mL/min): 3-4 days to clear
  • Moderate impairment (CrCl 30-50 mL/min): 4-5 days to clear
  • Severe impairment (CrCl 15-29 mL/min): 5+ days to clear 1

Procedure Planning After Hematoma Resolution

If procedures are needed after hematoma resolution, consider the following discontinuation timeline:

• Normal/mild renal impairment: Stop 3 days before procedure
• Moderate renal impairment: Stop 4 days before procedure
• Severe renal impairment: Stop 5 days before procedure 1

Potential Complications

Apixaban-related hematomas can occur in various locations with serious consequences:

• Intracranial hemorrhage 3, 4
• Rectus sheath hematoma 5
• Intramural bowel hematoma leading to intussusception 6
• Other soft tissue hematomas

Key Pitfalls to Avoid

1. Do not delay holding apixaban when a hematoma is suspected
2. Do not restart anticoagulation prematurely before adequate hemostasis is achieved
3. Do not underestimate the severity of anticoagulant-related bleeding complications
4. Do not rely on standard coagulation tests to assess apixaban activity
5. Do not bridge with heparin when stopping apixaban for procedures after hematoma resolution 1

By following this approach, you can minimize morbidity and mortality associated with apixaban-related hematomas while maintaining appropriate anticoagulation when it becomes safe to resume.