Should I hold Eliquis (apixaban) in a patient with a deep intramuscular hematoma on anticoagulation for a history of pulmonary embolism and factor V Leiden?

Management of Apixaban in a Patient with Deep Intramuscular Hematoma

Yes, you should hold Eliquis (apixaban) temporarily in a patient with a deep intramuscular hematoma who has a history of pulmonary embolism and Factor V Leiden. 1

Assessment of Bleeding Risk vs. Thrombotic Risk

Bleeding Considerations:

• Deep intramuscular hematoma represents an active bleeding event that requires immediate management 1
• Continuing anticoagulation could lead to hematoma expansion and increased morbidity 1
• Apixaban has a half-life of approximately 12 hours, with pharmacodynamic effects persisting for at least 24 hours after the last dose 2

Thrombotic Risk Assessment:

• Patient has two significant risk factors for recurrent VTE:
  • History of pulmonary embolism 1
  • Factor V Leiden thrombophilia 3, 4
• Factor V Leiden heterozygotes have a 2-3 fold increased risk of initial VTE but typically have a more modest effect on recurrence risk 3
• However, some cases of recurrent VTE in heterozygous Factor V Leiden patients have been reported 4

Management Algorithm

Immediate Management:

1. Hold Apixaban immediately due to active bleeding (deep intramuscular hematoma) 1
2. Monitor the hematoma for expansion and assess hemodynamic stability 1
3. Consider hemoglobin monitoring to assess bleeding severity 2

Duration of Anticoagulation Interruption:

• For high hemorrhagic risk situations, guidelines recommend interruption of direct oral anticoagulants (DOACs) like apixaban for up to 5 days 1
• The specific duration should depend on:
  • Size and stability of the hematoma 1
  • Resolution of active bleeding 1
  • Patient's renal function (as this affects apixaban clearance) 1

Resumption of Anticoagulation:

• Resume anticoagulation only when hemostasis is achieved and the bleeding risk has decreased 1
• Consider resuming at a therapeutic dose between 24-72 hours after bleeding has stopped 1
• If the thrombotic risk is very high, consider bridging with prophylactic-dose LMWH before resuming full anticoagulation 1

Long-term Management Considerations

After the acute bleeding episode resolves:

• Resume apixaban at the previous dose as the patient has a history of PE and Factor V Leiden, which warrants extended anticoagulation 1
• For patients with unprovoked PE and thrombophilia like Factor V Leiden, guidelines recommend extended anticoagulant therapy (no scheduled stop date) 1
• Monitor renal function periodically as it affects apixaban clearance and dosing 1

Important Caveats

• If bleeding persists or worsens, consider specific reversal strategies:
  • Activated charcoal if apixaban was recently ingested 2
  • Prothrombin complex concentrate may be considered for severe bleeding, though clinical evidence is limited 2
• Avoid concomitant use of antiplatelet agents or NSAIDs when anticoagulation is resumed, as these increase bleeding risk 1
• Routine monitoring of anti-Factor Xa activity is not recommended for apixaban management 1
• After resumption of anticoagulation, reassess the risk-benefit ratio periodically, especially if there are changes in the patient's clinical status 1