What to do if a patient taking Eliquis (apixaban) 5mg presents with hematuria?

Management of Blood-Tinged Urine in a Patient Taking Eliquis 5mg

For a patient taking Eliquis (apixaban) 5mg who presents with blood-tinged urine, the anticoagulant should be temporarily discontinued until the bleeding is controlled and a thorough urologic evaluation is completed.

Initial Assessment

When evaluating a patient with hematuria on Eliquis:

1. Assess severity of bleeding:

   • Quantify amount of blood in urine
   • Determine duration of hematuria
   • Check for associated symptoms (flank pain, dysuria, frequency)
   • Evaluate hemodynamic stability

2. Laboratory evaluation:

   • Complete blood count to assess for anemia
   • Serum creatinine to evaluate renal function
   • Calculate creatinine clearance using Cockcroft-Gault formula
   • Urinalysis to confirm hematuria and check for infection

Management Algorithm

Step 1: Immediate Management

• Temporarily discontinue Eliquis if hematuria is more than minimal 1
• Ensure adequate hydration to promote urinary flow
• Monitor vital signs and urine output

Step 2: Diagnostic Evaluation

• Full urologic evaluation is mandatory despite anticoagulant use 1, 2, 3
• Approximately 25% of patients with anticoagulant-associated hematuria have underlying tumors 1, 3
• Evaluation should include:
  • Urine cytology
  • Renal imaging (ultrasound or CT urogram)
  • Cystoscopy if gross hematuria or persistent microscopic hematuria

Step 3: Decision on Anticoagulation

If bleeding is minor and controlled:

• Consider restarting Eliquis once hematuria resolves
• Consider dose reduction if appropriate based on patient factors

If bleeding is significant or persistent:

• Consider switching to alternative anticoagulant with different mechanism
• Evaluate if antiplatelet agents can be safely discontinued if patient is on dual therapy 1

Important Considerations

Bleeding Risk with Apixaban

• Apixaban is associated with hemorrhage (including urethral hemorrhage) in 1.1% of patients 4
• Hematuria occurred in 1.7% of patients taking apixaban in the AMPLIFY study 4

Underlying Pathology

• Anticoagulant use does not cause hematuria but may unmask or exacerbate underlying conditions 3
• A study of patients on antithrombotic medications showed they were 1.85 times more likely to be diagnosed with bladder cancer within 6 months compared to those not on these medications 5

Anticoagulant-Related Nephropathy

• Rare but serious complication that can occur with apixaban 6
• Monitor kidney function after initiating anticoagulant therapy, especially if patient has preexisting renal impairment

Resuming Anticoagulation

When resuming anticoagulation after hematuria resolves:

1. Timing: Wait until bleeding is completely controlled 1

2. Dosing considerations:

   • Reassess renal function before restarting
   • Consider dose adjustment based on creatinine clearance
   • Apixaban is 27% renally cleared, making it preferable in patients with mild-moderate renal impairment 7

3. Follow-up:

   • Monitor for recurrence of hematuria
   • Regular renal function assessment, especially in elderly patients 1

Common Pitfalls to Avoid

1. Do not ignore hematuria simply because the patient is on an anticoagulant
2. Do not automatically attribute hematuria to anticoagulation without proper investigation
3. Do not restart anticoagulation before determining and addressing the underlying cause
4. Do not continue concomitant antiplatelet therapy without careful consideration of bleeding risk 1

For severe bleeding that requires immediate reversal of apixaban, andexanet alfa is the specific reversal agent, though prothrombin complex concentrate can be used if andexanet alfa is unavailable 7.