What are the guidelines for anticoagulation management in a patient with atrial fibrillation (AFib) on chronic anticoagulation with Eliquis (apixaban) who has suffered a large stroke involving the right Middle Cerebral Artery (MCA)?

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION

2.1 Recommended Dose Reduction of Risk of Stroke and Systemic Embolism in Patients with Nonvalvular Atrial Fibrillation The recommended dose of apixaban tablets for most patients is 5 mg taken orally twice daily.

The guidelines for anticoagulation management in a patient with atrial fibrillation (AFib) on chronic anticoagulation with Eliquis (apixaban) who has suffered a large stroke involving the right Middle Cerebral Artery (MCA) are not directly addressed in the provided drug label.

• Dosing: The label provides dosing recommendations for patients with nonvalvular atrial fibrillation, but it does not specifically address dosing after a stroke.
• Management after stroke: The label does not provide guidance on managing anticoagulation after a stroke. 1

From the Research

For a patient with atrial fibrillation on chronic Eliquis (apixaban) who has suffered a large right MCA stroke, anticoagulation should be temporarily discontinued for at least 7-9 days, as suggested by the AREST trial 2, before resuming therapy. The timing of resumption depends on several factors including stroke size, bleeding risk, and risk of recurrent stroke. For large strokes like an MCA infarct, waiting 2-4 weeks is generally advised, but recent evidence from the AREST trial 2 indicates that early initiation of anticoagulation after TIA, small-, or medium-sized AIS from AF does not appear to compromise patient safety. When restarting anticoagulation, resume the patient's previous dose of Eliquis (typically 5mg twice daily, or 2.5mg twice daily for patients meeting dose reduction criteria). During the period when anticoagulation is held, the patient should be monitored closely for neurological deterioration and hemorrhagic transformation. The temporary discontinuation is necessary because the risk of hemorrhagic transformation is highest in the acute post-stroke period, especially with large infarcts where damaged blood vessels are more prone to bleeding. Some key factors to consider in the decision to restart anticoagulation include:

• Stroke size: larger strokes are associated with a higher risk of hemorrhagic transformation
• Bleeding risk: patients with a high risk of bleeding may require closer monitoring or a longer period of anticoagulant discontinuation
• Risk of recurrent stroke: patients with a high risk of recurrent stroke may benefit from earlier restart of anticoagulation The decision to restart should be individualized based on repeat brain imaging to confirm absence of hemorrhagic transformation, stabilization of the neurological deficit, and assessment of the patient's overall clinical status. Some clinicians may consider bridging with prophylactic-dose heparin or LMWH for DVT prevention during this period, though this remains controversial in large strokes. It's worth noting that the AREST trial 2 provides the most recent and highest quality evidence on this topic, and its findings should be taken into consideration when making decisions about anticoagulation management in patients with atrial fibrillation who have suffered a large stroke.