Management of Hematuria and Clots While on Eliquis (Apixaban)
If you're experiencing clots and pain on urination while taking Eliquis, you should seek immediate medical attention as this may indicate significant urinary tract bleeding requiring evaluation and possible temporary discontinuation of your anticoagulant.
Assessment of Bleeding Severity
When experiencing hematuria (blood in urine) while on Eliquis, it's important to determine the severity:
Signs of Major Bleeding:
- Visible blood clots in urine
- Pain during urination
- Hemodynamic instability (rapid heart rate, low blood pressure)
- Significant discomfort
Laboratory Evaluation:
- Complete blood count to assess for anemia
- Serum creatinine to evaluate kidney function
- Urinalysis to confirm hematuria and check for infection 1
Management Algorithm
1. For Minor Hematuria (Minimal blood, no clots, no pain):
- Continue Eliquis if bleeding is minimal
- Increase fluid intake to promote dilution and flushing of the urinary tract
- Monitor for worsening symptoms
- Follow up with healthcare provider within 1-2 days
2. For Moderate to Severe Hematuria (Clots, pain, discomfort):
- Seek immediate medical attention
- Temporarily discontinue Eliquis
- Provide local therapy/manual compression if applicable
- Receive supportive care and volume resuscitation if needed 2
- Undergo urologic evaluation including:
- Urine cytology
- Renal imaging
- Possible cystoscopy 1
3. For Life-Threatening Bleeding:
- Immediate hospitalization
- Discontinue Eliquis
- Consider reversal agent (andexanet alfa) for uncontrolled bleeding 2
- Supportive measures including fluid resuscitation
- Urgent urologic consultation
Important Considerations
Potential Causes to Investigate:
- Urinary tract infection
- Kidney stones
- Urologic malignancy
- Medication-induced hemorrhagic cystitis
- Comorbidities that could contribute to bleeding (thrombocytopenia, uremia, liver disease) 2
Restarting Anticoagulation:
Once bleeding has stopped and the cause has been identified and treated:
- Consider restarting Eliquis after 24-72 hours if the bleeding risk is acceptable 1
- Possible dose reduction based on patient factors
- Regular monitoring of renal function is essential 1
Precautions and Follow-up
Medication Interactions:
- Review all medications for potential interactions with Eliquis
- Particularly concerning are:
- P-glycoprotein inhibitors
- CYP3A4 inhibitors
- Concomitant antiplatelet agents (significantly increase bleeding risk) 3
Warning Signs Requiring Immediate Attention:
- Worsening hematuria
- Development of flank pain
- Fever
- Inability to urinate due to clots
- Signs of hemodynamic instability (dizziness, rapid heart rate)
Conclusion
Hematuria with clots and pain while on Eliquis represents a potentially serious complication that requires prompt medical evaluation. The European Association of Urology recommends sonography and CT examination of the urinary tract as initial diagnostic steps 1. While temporary discontinuation of anticoagulation may be necessary, the decision to restart therapy should be based on a careful assessment of both thrombotic and bleeding risks.