Should aspirin be added to an 86-year-old patient with impaired cerebral function (subacute stroke) while on Eliquis (apixaban)?

Management of Aspirin Therapy in an 86-Year-Old Patient with Subacute Stroke on Eliquis

Adding aspirin to an 86-year-old patient who had a subacute stroke while on Eliquis (apixaban) is not recommended due to increased bleeding risk without clear additional benefit for stroke prevention.

Rationale for Not Adding Aspirin

Anticoagulation vs. Antiplatelet Therapy

• Patients who have had a stroke while on anticoagulation therapy (like Eliquis) represent a therapeutic challenge, but adding aspirin to anticoagulation significantly increases bleeding risk
• The National Stroke Association guidelines clearly state that for patients with a cardioembolic TIA who are already on adequate oral anticoagulation, adding antiplatelet therapy is only recommended in specific circumstances like prosthetic heart valves 1
• For patients with non-cardioembolic stroke, oral anticoagulation is not recommended because there is no documented evidence of higher benefit compared to antiplatelet therapy alone, while the risk for cerebral hemorrhagic complications is higher 1

Age-Related Considerations

• At 86 years old, this patient falls into a high-risk category for bleeding complications with combined therapy
• The 2024 AHA/ASA guidelines specifically recommend against aspirin use in individuals ≥70 years of age with cardiovascular risk factors as it is not beneficial for stroke prevention and increases bleeding risk 1
• The ASPREE trial demonstrated no reduction in stroke with aspirin therapy in patients ≥70 years of age but did show a small increase (0.7% absolute) in intracranial bleeding 1

Appropriate Management Strategy

Evaluation of Current Anticoagulation

1. Assess whether the patient's apixaban dosing is appropriate:

   • Standard dose: 5 mg twice daily
   • Reduced dose (2.5 mg twice daily) if patient has at least two of: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL

2. Verify medication adherence:

   • Confirm the patient has been taking Eliquis as prescribed
   • Check for any drug interactions that might reduce apixaban efficacy

3. Consider potential causes of anticoagulation failure:

   • Evaluate for uncontrolled hypertension
   • Assess for other stroke risk factors that might not be addressed by anticoagulation

Alternative Approaches

If stroke occurred despite appropriate anticoagulation:

1. For patients with atrial fibrillation:

   • Consider switching to a different direct oral anticoagulant (DOAC) or warfarin
   • Do not add aspirin, as the AHA/ASA guidelines note "there is no evidence that combining anticoagulation with an antiplatelet agent reduces the risk of stroke or MI compared with anticoagulant therapy alone in AF patients, but there is clear evidence of increased bleeding risk" 1

2. For patients with non-cardioembolic stroke:

   • If the stroke is determined to be non-cardioembolic in origin, consider whether anticoagulation is the appropriate therapy
   • For non-cardioembolic strokes, antiplatelet therapy alone may be more appropriate than anticoagulation 1

Special Considerations in Elderly Patients

• Bleeding risk increases substantially with age, particularly in patients >75 years
• The Australian Clinical Guidelines for Acute Stroke Management recommend antiplatelet therapy for people with ischemic stroke to prevent DVT/PE, but not in addition to anticoagulation 1
• In patients >70 years, the risk-benefit ratio strongly favors avoiding combination therapy due to significantly increased bleeding risk 1, 2

Conclusion

For an 86-year-old patient who experienced a stroke while on Eliquis, the most appropriate approach is to optimize the current anticoagulation regimen rather than adding aspirin. The increased bleeding risk from combination therapy outweighs potential benefits, particularly in this elderly population. Focus should be placed on addressing modifiable risk factors and ensuring optimal dosing and adherence to the anticoagulant medication.