Should I hold Eliquis (apixaban) and Plavix (clopidogrel) in a patient with hematuria lasting 10 days?

Management of Hematuria in a Patient on Eliquis and Plavix

For a patient with hematuria lasting 10 days while on Eliquis (apixaban) and Plavix (clopidogrel), both medications should be temporarily held until complete resolution of hematuria, with Eliquis held for at least 48-72 hours and resumption only after adequate hemostasis is established. 1

Initial Management

• Immediately hold both Eliquis and Plavix
• Ensure adequate hydration
• Monitor vital signs and hemoglobin levels
• Consider urinary catheter placement for severe cases
• Assess severity of bleeding (mild, moderate, or severe)

Duration of Medication Hold

For Eliquis (apixaban):

• Mild hematuria: Hold for at least 48 hours 1
• Moderate to severe hematuria: Hold for at least 72 hours or until complete resolution 1
• Consider drug half-life based on renal function:
  • Normal renal function: 6-15 hours
  • Moderate impairment: 18 hours
  • Severe impairment: 27 hours

For Plavix (clopidogrel):

• Hold for at least 5-7 days due to its irreversible platelet inhibition effect
• Platelet function typically normalizes 5-7 days after discontinuation

Diagnostic Evaluation While Medications Are Held

• Urologic evaluation is crucial as 25-30% of patients with anticoagulant-associated hematuria have underlying urologic malignancies 1
• Consider:
  • Complete blood count
  • Coagulation profile
  • Renal function tests
  • Urinalysis
  • Imaging (ultrasound or CT urogram)
  • Cystoscopy if hematuria persists or recurs

Risk Assessment Before Resuming Medications

Thrombotic Risk Assessment:

• High risk: Recent venous thromboembolism (within 3 months), mechanical heart valve, atrial fibrillation with recent stroke
• Moderate risk: Atrial fibrillation with multiple risk factors, recent venous thromboembolism (3-12 months)
• Low risk: Atrial fibrillation with few risk factors, venous thromboembolism >12 months ago

Bleeding Risk Assessment:

• Consider factors such as age, renal function, history of bleeding, concomitant medications
• Patients on dual therapy (anticoagulant plus antiplatelet) have significantly higher rates of hematuria-related complications (191.61 events per 1000 person-years) compared to those on single therapy or no therapy 2

Resuming Medications

• Resume only after complete resolution of gross hematuria

• Wait at least 24-48 hours after resolution before restarting 1

• Consider staggered resumption:

  1. Resume the medication with higher thrombotic risk prevention value first
  2. Monitor for 24-48 hours
  3. If no recurrent bleeding, resume the second medication

• For high thrombotic risk patients with persistent mild hematuria, consider resuming Eliquis at a reduced dose initially 1

Important Considerations

• Rivaroxaban and warfarin appear to be associated with higher rates of hematuria compared to apixaban 3
• Combination therapy with both anticoagulant and antiplatelet agents significantly increases bleeding risk 2
• A full urologic evaluation is warranted even if excessive anticoagulation is present, as tumors are diagnosed in approximately 25% of patients with hematuria on anticoagulants 4

Follow-up

• Schedule close follow-up after resuming anticoagulation to detect recurrent bleeding
• Monitor for signs of thrombosis during medication interruption
• Consider long-term urologic follow-up if indicated by initial evaluation

Remember that hematuria lasting 10 days is concerning and warrants thorough investigation regardless of anticoagulant use, as it may indicate significant underlying pathology.