Should Eliquis (apixaban) be stopped in a patient with atrial fibrillation who develops microscopic hematuria?

Management of Microscopic Hematuria in a Patient with Atrial Fibrillation on Eliquis

Eliquis should be temporarily discontinued while the patient undergoes thorough evaluation for the cause of microscopic hematuria, as this finding warrants investigation regardless of anticoagulation status. 1

Initial Assessment

When a patient on anticoagulation presents with microscopic hematuria, it's crucial to recognize that this is not simply an expected side effect of anticoagulation therapy but may indicate underlying pathology that requires investigation.

The 2020 ACC Expert Consensus Decision Pathway recommends temporarily discontinuing oral anticoagulant therapy when a non-major bleed occurs and any of the following apply 1:

• Further diagnostic evaluation is warranted to determine the site or clinical impact of bleeding
• An invasive procedure may be needed soon
• There is concern for a slow bleed from a critical site

Evaluation Algorithm

1. Temporarily discontinue Eliquis

   • This allows for proper evaluation without the confounding effect of anticoagulation
   • Document the time of last dose

2. Urgent urological evaluation

   • Complete urinalysis with microscopy
   • Urine cytology
   • Renal ultrasound
   • Consider cystoscopy based on risk factors
   • Intravenous pyelography if upper tract pathology suspected

3. Risk assessment for underlying malignancy

   • Age >60 years increases risk
   • History of smoking
   • Occupational exposures to chemicals
   • Prior pelvic radiation
   • Chronic urinary tract infections

Rationale for Investigation

Microscopic hematuria in anticoagulated patients should not be attributed solely to anticoagulation therapy. Research has demonstrated that hematuria in patients on anticoagulants can be indicative of underlying pathology, including malignancy 2. Early identification of conditions like bladder cancer allows for timely intervention and improved outcomes.

Restarting Anticoagulation

After evaluation is complete and no serious pathology is identified, or after appropriate treatment of any identified cause:

• If no significant pathology found: Resume Eliquis once hemostasis is achieved 1
• If malignancy or other significant pathology identified: Multidisciplinary discussion regarding the risk-benefit of resuming anticoagulation is recommended 1

Important Considerations

• Stroke risk: Remember that temporarily stopping anticoagulation increases stroke risk in patients with atrial fibrillation
• Duration of interruption: Keep the interruption as brief as possible while allowing for adequate evaluation
• Bridging therapy: Generally not required for short interruptions of Eliquis due to its short half-life

Common Pitfalls to Avoid

1. Ignoring microscopic hematuria: Assuming it's merely a consequence of anticoagulation can lead to delayed diagnosis of serious conditions
2. Prolonged anticoagulation interruption: Increases stroke risk unnecessarily
3. Failure to investigate: Even in patients on anticoagulation, microscopic hematuria warrants a complete urological evaluation

Remember that while anticoagulation increases bleeding risk, it does not typically cause microscopic hematuria in the absence of underlying pathology. The European Society of Cardiology guidelines emphasize that when bleeding events occur, the cause should be assessed and corrected if possible 1.