What to do if an 81-year-old female patient on Eliquis (apixaban) and Plavix (clopidogrel) presents with lower gastrointestinal (GI) bleeding and hematochezia (bright blood per rectum)?

Management of Lower GI Bleeding in an 81-Year-Old Female on Eliquis and Plavix

For an 81-year-old female patient on Eliquis (apixaban) and Plavix (clopidogrel) presenting with lower GI bleeding and bright blood per rectum, immediate interruption of both anticoagulant and antiplatelet therapy is recommended, with management in consultation with cardiology regarding the timing of medication resumption.

Initial Assessment and Stabilization

• Assess hemodynamic stability immediately:

  • Calculate shock index (heart rate divided by systolic blood pressure) - shock index >1 indicates unstable bleeding 1
  • Establish two large-bore IV access for fluid resuscitation 1
  • Obtain complete blood count, coagulation profile, and type and cross-match 1

• Blood transfusion considerations:

  • Use restrictive RBC transfusion threshold (Hb trigger 70 g/L and target 70-90 g/L) 2
  • For patients with cardiovascular disease, use higher threshold (Hb trigger 80 g/L and target 100 g/L) 2

Management of Anticoagulant and Antiplatelet Medications

Apixaban (Eliquis) Management:

• Interrupt apixaban immediately 2, 3
• Consider reversal with andexanet alfa only for life-threatening hemorrhage 2
• Monitor for 24-48 hours as anticoagulant effect can persist 3

Clopidogrel (Plavix) Management:

• Interrupt clopidogrel immediately 2
• Do not administer platelet transfusions unless there is life-threatening bleeding 4
• For patients with coronary stents, management should be in liaison with a cardiologist 2
• If the patient has coronary stents, consider continuing aspirin if Plavix must be interrupted 2

Diagnostic Approach

1. Upper GI Endoscopy first:

   • Even in suspected lower GI bleeding, 10-15% of severe hematochezia cases have upper GI sources 1

2. CT Angiography (CTA):

   • High sensitivity (80-90%) for detecting active bleeding 1
   • Provides anatomical information to guide subsequent interventions 1

3. Colonoscopy:

   • After adequate bowel preparation if patient is stable 2
   • Can provide both diagnosis and therapeutic intervention 2

Therapeutic Interventions

• Endoscopic therapy: Apply clips, thermal therapy, or injection therapy once bleeding source is identified 1

• Angiographic embolization: Consider if endoscopic therapy fails or is not feasible, particularly effective for diverticular bleeding and angiodysplasia 1

• Surgical intervention: Consider if bleeding persists despite other interventions, requiring >6 units of blood, or with recurrent severe bleeding 1

Resumption of Anticoagulant and Antiplatelet Therapy

Apixaban:

• Consider restarting at a maximum of 7 days after hemostasis is achieved 2
• For patients with high thrombotic risk, consider bridging with low molecular weight heparin 48 hours after bleeding has stopped 2

Clopidogrel:

• P2Y12 receptor antagonist therapy should be reinstated within 5 days 2
• For dual antiplatelet therapy with coronary stents, management should be coordinated with cardiology 2

Important Considerations and Pitfalls

• Age-related risk: Patients over 70 years have higher risk of both bleeding and thrombotic complications 2, 1

• Drug interactions: NSAIDs should be strictly avoided as they significantly increase bleeding risk 1, 5

• Proton pump inhibitors: Consider adding a PPI as they substantially decrease upper GI bleeding risk with antiplatelet therapy 5

• Monitoring: Close observation for rebleeding is essential, particularly in the first 24-48 hours 2

• Common causes in elderly: Diverticular disease and angiodysplasia are common causes of lower GI bleeding in patients over 70 years 2

• Mortality risk: In-hospital mortality for lower GI bleeding is 3.4%, rising to 20% in patients requiring ≥4 units of blood transfusion 2

This approach balances the risks of continued bleeding against thrombotic complications from medication discontinuation, with decisions guided by the patient's hemodynamic status and consultation with cardiology regarding the timing of antiplatelet therapy resumption.