How many falls are required before stopping Eliquis (apixaban) in patients with atrial fibrillation (AFib)?

Fall Risk and Anticoagulation in Atrial Fibrillation

There is no specific number of falls that automatically warrants discontinuation of Eliquis (apixaban) in patients with atrial fibrillation, as the benefits of stroke prevention typically outweigh the bleeding risks even in patients with high fall risk.

Risk-Benefit Assessment

The decision to continue or discontinue anticoagulation in patients with AF who fall requires careful consideration of:

1. Stroke Risk vs. Bleeding Risk

   • Patients with AF and a history of falling have higher rates of major bleeding, including intracranial bleeding, compared to those without a fall history 1
   • However, these patients also have higher rates of ischemic stroke (13.7 vs 6.9 per 100 patient-years) 2

2. Evidence Supporting Continued Anticoagulation

   • Mathematical modeling suggests an older adult would need to fall over 458 times per year for the risks of apixaban to outweigh its benefits compared to aspirin 3
   • In the ARISTOTLE trial, apixaban showed consistent benefits over warfarin regardless of fall history, with notably zero subdural bleeds in the apixaban group among patients with fall history (compared to 5 in the warfarin group) 1

Risk Factors for Falls in Anticoagulated Patients

Several factors increase fall risk in patients on anticoagulation:

• Older age
• Osteoporosis
• Use of medications such as:
  • Amiodarone
  • Diuretics
  • Short and medium-acting benzodiazepines 4

Decision-Making Algorithm

1. Assess stroke risk using CHA₂DS₂-VASc score

   • Score ≥2 in men or ≥3 in women indicates high stroke risk 5

2. Assess bleeding risk using HAS-BLED score

   • Score ≥3 indicates high bleeding risk 5

3. Evaluate fall risk using validated tools like the Morse Fall Scale 4

4. Consider anticoagulation management based on risk assessment:

   • For patients with high stroke risk (CHA₂DS₂-VASc ≥2 in men, ≥3 in women):
     • Continue Eliquis despite falls if the patient can be safely monitored
     • Consider dose reduction to 2.5 mg twice daily if patient is ≥80 years old, weighs ≤60 kg, or has serum creatinine ≥1.5 mg/dL 5
   • For patients with both high stroke risk AND severe/uncontrollable fall risk:
     • Consider left atrial appendage closure as an alternative to anticoagulation
     • If anticoagulation must be continued, apixaban is preferred over warfarin due to lower intracranial bleeding risk 1

Monitoring Recommendations

For patients with AF and fall risk who remain on anticoagulation:

• Implement fall prevention strategies
• Monitor more frequently (every 3-6 months) 5
• Assess medication adherence, renal function, and drug interactions
• Evaluate for signs of occult bleeding

Key Points to Remember

• Fall risk alone is generally not sufficient reason to withhold anticoagulation in AF patients
• Apixaban has been shown to have a better safety profile than warfarin in patients with fall history 1
• The consequences of withholding anticoagulation (stroke) are often more devastating than the risks of continuing it (bleeding)
• Type and quality of anticoagulation significantly affect survival after falls, with patients on apixaban showing better outcomes 4

The decision to discontinue anticoagulation should be based on a comprehensive risk assessment rather than simply counting the number of falls, as even patients with multiple falls typically benefit from continued anticoagulation, particularly with apixaban.