What is the management approach for a patient on long-term Plavix (clopidogrel) and Eliquis (apixaban) presenting with moderate to large amounts of frank red blood in stool?

Management of Acute Lower GI Bleeding in a Patient on Plavix and Eliquis

A patient on dual antithrombotic therapy with Plavix (clopidogrel) and Eliquis (apixaban) presenting with moderate to large amounts of frank red blood in stool requires immediate discontinuation of both antithrombotics, urgent resuscitation, and colonoscopy within 24 hours after adequate bowel preparation. 1, 2

Initial Assessment and Management

Immediate Steps:

• Assess hemodynamic status and initiate resuscitation if needed
• Maintain hemoglobin >7 g/dL (target 70-90 g/L)
• Target mean arterial pressure >65 mmHg
• Interrupt both Plavix and Eliquis immediately 1

Reversal Considerations:

• For life-threatening hemorrhage on Eliquis, consider andexanet alfa 1, 2
• No specific reversal agent exists for Plavix; platelet transfusion may be considered in severe, life-threatening bleeding

Diagnostic Approach

1. Rule out upper GI source: Up to 8% of suspected lower GI bleeding may have an upper source, especially with hemodynamic instability 2

2. Colonoscopy: Should be performed within 24 hours after adequate bowel preparation 2, 3

   • Allows for both diagnosis and potential therapeutic intervention
   • Endoscopic hemostasis should be provided for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot)

3. If bleeding is severe and ongoing:

   • CT Angiography (CTA) should be performed in patients with ongoing bleeding who are hemodynamically stable after resuscitation 2
   • Consider interventional radiology if endoscopic management fails

Antithrombotic Management

During Acute Bleeding:

• Interrupt both Plavix and Eliquis at presentation 1
• If the patient has coronary stents, consult cardiology regarding the management of Plavix interruption 1

Resumption Strategy:

• Eliquis: Resume at a maximum of 7 days after bleeding is controlled 1, 2
• Plavix: P2Y12 receptor antagonist therapy should be reinstated within 5 days after hemostasis is achieved 1

Special Considerations:

• If the patient is on Plavix for secondary prevention (e.g., coronary stents), the thrombotic risk is high
• The decision to restart antithrombotics must balance the risk of rebleeding against the risk of thrombotic events
• Patients who discontinue antithrombotics have fewer rebleeding events but significantly more cardiovascular events and deaths 1

Prevention of Recurrent Bleeding

• Once hemostasis is achieved, consider proton pump inhibitor therapy if upper GI pathology is identified
• Avoid NSAIDs in the future, particularly if bleeding is due to diverticulosis or angioectasia 4
• Schedule follow-up within 2 weeks of discharge 2
• Arrange cardiology follow-up to assess stent status and optimize antiplatelet regimen 2

Common Pitfalls to Avoid

1. Delaying colonoscopy: Urgent colonoscopy within 24 hours after adequate bowel preparation is essential for diagnosis and potential therapeutic intervention

2. Prolonged discontinuation of antithrombotics: Extended interruption of antithrombotic therapy, especially in patients with coronary stents, increases the risk of thrombotic events

3. Failing to consult cardiology: Multidisciplinary approach involving cardiology is crucial for patients on dual antithrombotic therapy

4. Inadequate follow-up: Ensure proper follow-up to monitor for rebleeding and adjust antithrombotic therapy as needed

The management of this patient requires careful balancing of bleeding and thrombotic risks, with the goal of achieving hemostasis while minimizing the risk of thrombotic complications from prolonged antithrombotic interruption.