Should I hold Eliquis (apixaban) after an unwitnessed fall?

Management of Apixaban After an Unwitnessed Fall

After an unwitnessed fall, you should temporarily hold apixaban for 24-48 hours and evaluate for intracranial hemorrhage before resuming. 1

Initial Assessment After Fall

• Perform immediate neurological assessment looking for:

  • Altered mental status
  • New focal neurological deficits
  • Headache
  • Vomiting
  • Changes in vision
  • Loss of consciousness

• Risk factors that warrant more caution:

  • Age ≥80 years
  • History of prior falls or bleeding
  • Concurrent antiplatelet therapy
  • Renal impairment

Evaluation Protocol

1. Immediate evaluation:

   • Neurological examination
   • Head CT scan if any concerning symptoms or signs
   • Monitor for delayed symptoms (24 hours)

2. Laboratory assessment:

   • Complete blood count
   • Renal function (creatinine clearance affects apixaban half-life)
   • Coagulation parameters

Decision Algorithm for Apixaban Management

If No Concerning Symptoms:

• Hold apixaban for 24 hours
• Monitor neurologically every 4 hours for 24 hours
• Resume apixaban after 24 hours if no concerning symptoms develop 1

If Concerning Symptoms or High-Risk Patient:

• Hold apixaban for 48 hours
• Obtain urgent head CT
• Consider neurological consultation
• Resume only after intracranial hemorrhage has been ruled out

If Intracranial Hemorrhage Detected:

• Continue holding apixaban
• Consider reversal with andexanet alfa if active bleeding 1, 2
• If andexanet alfa is unavailable, administer prothrombin complex concentrate (PCC)

Considerations for Resumption

The American College of Cardiology recommends resuming anticoagulation once the patient is stable and intracranial hemorrhage has been ruled out 1. When resuming:

• Consider the half-life of apixaban (6-15 hours with normal renal function) 1
• For patients with renal impairment (CrCl 15-29 mL/min), half-life extends to approximately 17 hours 1
• Ensure adequate hemostasis is established before resuming

Special Considerations

• Patients with high thrombotic risk: Consider bridging with prophylactic dose heparin if apixaban must be held for >48 hours
• Patients with history of falls: Research from the ARISTOTLE trial showed that patients with atrial fibrillation and a history of falling have higher risk of major bleeding, including intracranial bleeding, but the benefits of apixaban over warfarin remained consistent in this population 3
• Avoid unnecessary bridging: The American College of Chest Physicians recommends against preoperative bridging when interrupting direct oral anticoagulants like apixaban 4

Common Pitfalls to Avoid

1. Resuming anticoagulation too early without proper evaluation
2. Failing to adjust management based on renal function
3. Not considering the patient's thrombotic risk when holding anticoagulation
4. Inadequate monitoring during the observation period
5. Overlooking subtle neurological changes that might indicate bleeding

Remember that the FDA label for apixaban specifically warns that it increases the risk of bleeding and can cause serious, potentially fatal bleeding 2. Therefore, a cautious approach with temporary discontinuation after an unwitnessed fall is warranted to ensure patient safety.