What is the proper management for a patient with hematochezia after switching from Warfarin (Coumadin) to Eliquis (Apixaban)?

From the Guidelines

The patient with hematochezia after switching from Warfarin to Eliquis (Apixaban) should immediately stop taking Eliquis and seek emergency care, as gastrointestinal bleeding is a serious adverse effect of anticoagulants that can be life-threatening. This patient requires prompt medical evaluation, including a complete blood count to assess for anemia, checking coagulation parameters, and evaluating the severity of bleeding through endoscopic procedures 1. Management may include fluid resuscitation, blood transfusion if hemoglobin is significantly decreased, and possibly administration of reversal agents like andexanet alfa for severe bleeding. Some key points to consider in the management of this patient include:

• The healthcare provider should consider treatment with inhibitors such as idarucizumab or andexanet for life-threatening haemorrhage on direct oral anticoagulants, as recommended by the British Society of Gastroenterology 1.
• The patient's renal function should be taken into account when managing the bleeding, as the half-life of Apixaban may be prolonged in renal failure 1.
• After the bleeding is controlled, the provider will reassess the need for anticoagulation and may consider alternative medications or dosing strategies based on the patient's risk factors for both thrombosis and bleeding.
• The underlying cause of the gastrointestinal bleeding should also be identified and treated to prevent recurrence.
• According to the guidelines from the British Society of Gastroenterology, restarting DOAC treatment at a maximum of 7 days after haemorrhage may be reasonable in most cases, based on experience with warfarin 1.
• It is essential to weigh the risks and benefits of anticoagulation in this patient, considering their individual risk factors for thrombosis and bleeding, and to make a decision based on the most recent and highest quality evidence available 1.

From the FDA Drug Label

5.2 Bleeding Apixaban tablets increases the risk of bleeding and can cause serious, potentially fatal, bleeding Concomitant use of drugs affecting hemostasis increases the risk of bleeding. Discontinue apixaban tablets in patients with active pathological hemorrhage. An agent to reverse the anti-factor Xa activity of apixaban is available

The proper management for a patient with hematochezia after switching from Warfarin (Coumadin) to Eliquis (Apixaban) is to discontinue apixaban tablets in patients with active pathological hemorrhage. An agent to reverse the anti-factor Xa activity of apixaban is available and should be considered in this situation 2.

From the Research

Management of Hematochezia after Switching from Warfarin to Eliquis (Apixaban)

• The management of hematochezia, a type of gastrointestinal bleeding, in patients who have switched from Warfarin to Eliquis (Apixaban) involves several considerations, including the severity of the bleeding, the patient's overall health, and the risk of thromboembolic events 3, 4, 5, 6, 7.
• According to a study published in 2018, the incidence of hospitalization for upper gastrointestinal tract bleeding was lower for patients prescribed Apixaban compared to those prescribed Rivaroxaban, Dabigatran, or Warfarin 4.
• Another study published in 2018 found that gastrointestinal bleeding in patients taking Direct-Acting Oral Anticoagulants (DOACs) may be less severe compared to those taking Warfarin, despite a higher frequency of bleeding 5.
• The reversal of anticoagulation and management of bleeding in patients on anticoagulants, including Apixaban, involves risk-stratification based on hemodynamic instability, source of bleeding, and degree of blood loss, as well as the use of specific antidotes and transfusion of blood products 6.
• A study published in 2017 recommended resuming anticoagulation therapy between 7 and 14 days following gastrointestinal bleeding, with Apixaban being a preferred option when restarting a DOAC therapy due to its lower risk of gastrointestinal bleeding compared to other DOACs 7.

Treatment Options

• Discontinuation of anticoagulant therapy may be sufficient for minor bleeding, while major bleeding may require transfusion of blood products and use of specific antidotes 6.
• The use of proton pump inhibitors (PPIs) may reduce the risk of upper gastrointestinal tract bleeding in patients taking anticoagulants, including Apixaban 4.
• Idarucizumab has been approved for dabigatran reversal, while andexanet alfa is expected to be approved for reversal of oral factor Xa inhibitors, including Apixaban 6.

Considerations for Resuming Anticoagulation Therapy

• Resuming anticoagulation therapy is recommended to reduce the risk of thromboembolic events, with the optimal timing being between 7 and 14 days following gastrointestinal bleeding 7.
• The choice of anticoagulant therapy, including Apixaban, should be based on the patient's individual risk factors and the severity of the bleeding event 7.