When to Hold Eliquis (Apixaban) for Thrombocytopenia
Eliquis should be held when platelet counts fall below 50 × 10^9/L and should not be resumed until platelet counts recover to above this threshold. 1
Platelet Count Thresholds for Anticoagulation Management
The management of anticoagulation in patients with thrombocytopenia should follow these guidelines:
Platelet count < 50 × 10^9/L: Withhold Eliquis and all other anticoagulants. Consider platelet transfusion if anticoagulation treatment is urgent. 1
Platelet count 50-80 × 10^9/L: Use Eliquis with caution, closely monitor for bleeding signs, and consider dose reduction if clinically appropriate. 1
Platelet count > 80 × 10^9/L: Standard Eliquis dosing can be used with regular monitoring. 1
Risk Stratification and Special Considerations
The decision to hold or continue Eliquis should also consider:
Acute thrombosis risk: For patients with high-risk features (symptomatic PE, proximal DVT) during the first 30 days and platelet count <50 × 10^9/L, consider platelet transfusion support to maintain counts above 40-50 × 10^9/L to enable continued anticoagulation. 1
Bleeding risk: Assess for active bleeding, which would further support holding anticoagulation.
Underlying cause of thrombocytopenia: Determine if the low platelet count is due to:
- Medication effect
- Underlying disease
- Heparin-induced thrombocytopenia (HIT)
Monitoring Recommendations
When managing patients on Eliquis with thrombocytopenia:
- Monitor platelet counts regularly (at least weekly if counts are borderline or declining)
- Assess for signs of bleeding
- Evaluate trends in platelet counts to anticipate need for dose adjustment or discontinuation
- Consider more frequent monitoring in patients with fluctuating platelet counts
Important Caveats
Direct oral anticoagulants (DOACs) like Eliquis lack robust data in severe thrombocytopenia: The International Society on Thrombosis and Haemostasis advises against using DOACs in patients with severe thrombocytopenia (<50 × 10^9/L). 1
Alternative anticoagulants: In cases where anticoagulation is absolutely necessary despite severe thrombocytopenia, consider alternative agents with shorter half-lives or those that can be more easily reversed.
Paradoxical thrombosis risk: Some thrombocytopenic conditions (like HIT) can paradoxically increase thrombosis risk despite low platelet counts, requiring careful individualized management. 1
Resumption of therapy: When platelet counts recover to >50 × 10^9/L, Eliquis can be resumed at standard dosing with close monitoring.
By following these guidelines, clinicians can appropriately balance the risks of thrombosis and bleeding when managing patients on Eliquis who develop thrombocytopenia.