What is the management plan for an 89-year-old patient with a gastrointestinal (GI) bleed on Eliquis (apixaban) for paroxysmal atrial fibrillation (A Fib) with possible iron deficiency anemia as a cause of bleeding?

Management of GI Bleed in an 89-Year-Old on Apixaban with Iron Deficiency Anemia

For an 89-year-old patient with GI bleeding on apixaban for paroxysmal atrial fibrillation and iron deficiency anemia, the immediate management should include temporary discontinuation of apixaban, evaluation of bleeding source, and intravenous iron replacement therapy.

Initial Assessment and Management

1. Anticoagulation Management:

   • Temporarily discontinue apixaban due to active GI bleeding 1
   • Consider the risk of thrombotic events with discontinuation, but active pathological hemorrhage necessitates stopping the anticoagulant
   • Do not administer prothrombin complex concentrate (PCC) unless there is life-threatening bleeding, as routine reversal is not recommended 2

2. Bleeding Source Identification:

   • Perform upper GI endoscopy to identify potential bleeding sources (can identify causes in 30-50% of patients) 3
   • Include small bowel biopsies during endoscopy to rule out celiac disease (present in 2-3% of IDA patients) 3
   • Follow with lower GI tract examination (colonoscopy preferred) as dual pathology occurs in 10-15% of patients 3
   • Consider capsule endoscopy if initial endoscopic evaluations are negative, as small bowel angioectasias are common in elderly patients 3

3. Iron Deficiency Management:

   • Confirm iron deficiency with serum ferritin (diagnostic if <12 μg/dl) 3
   • Note that inflammatory conditions may elevate ferritin despite iron deficiency 3, 4
   • Consider transferrin saturation (<30% suggests iron deficiency) 3

Iron Replacement Therapy

• Intravenous iron is preferred in this patient due to:

  • Active GI bleeding 3
  • Elderly age with likely poor oral iron absorption
  • Need for rapid repletion of iron stores 3
  • IV iron formulations that can replace deficits in 1-2 infusions are preferred 3

• Oral iron supplementation is less suitable because:

  • Poor absorption during active bleeding
  • Common side effects (nausea, abdominal pain, constipation) 3
  • Slower correction of anemia

Specific Considerations for This Patient

1. Atrial Fibrillation and Anticoagulation:

   • After achieving hemostasis, reassess the need for anticoagulation
   • Consider switching to a different DOAC as apixaban, while generally safer, has been associated with GI bleeding in elderly patients with anemia 5
   • Do not restart anticoagulation until hemostasis is confirmed endoscopically 2

2. Investigation for Specific Causes:

   • Evaluate for angioectasias, which are common in elderly patients and can cause recurrent GI bleeding 3, 6
   • Consider NSAID use as a potential contributing factor 3
   • Rule out malignancy, particularly colonic and gastric cancers 3

3. Treatment of Underlying Causes:

   • If angioectasias are identified, consider endoscopic therapy with argon plasma coagulation or hemostatic clips 3
   • For refractory bleeding from angioectasias, consider somatostatin analogues like lanreotide 6
   • Treat any identified inflammation to enhance iron absorption 3

Follow-up and Monitoring

• Monitor hemoglobin and iron parameters (ferritin, transferrin saturation) to assess response to therapy
• Reassess the need for long-term iron supplementation based on resolution of bleeding and correction of anemia
• Consider periodic endoscopic surveillance if a high-risk lesion is identified
• Evaluate the risk-benefit ratio of resuming anticoagulation once bleeding has resolved

Pitfalls to Avoid

• Do not assume iron deficiency is solely due to dietary factors in elderly patients; GI investigation is still required 3
• Do not accept minor findings like erosions or mild esophagitis as the sole cause of iron deficiency without completing full evaluation 3
• Do not restart anticoagulation prematurely before achieving hemostasis
• Avoid oral iron as first-line therapy in patients with active bleeding or conditions that impair absorption 3