What to do for a patient on Eliquis (apixaban) with hematuria?

Management of Hematuria in a Patient on Apixaban (Eliquis)

For a patient on Eliquis with bright red blood in urine, you should temporarily discontinue apixaban, provide supportive care, and assess the severity of bleeding to determine if reversal agents are needed. 1

Assessment of Bleeding Severity

First, determine if the hematuria represents a major or non-major bleed:

Major Bleeding Criteria (if any of these apply):

• Bleeding at a critical site (e.g., intracranial, intraocular, retroperitoneal) 1
• Hemodynamic instability 1
• Hemoglobin decrease ≥2 g/dL or administration of ≥2 units of blood 1

Management Algorithm Based on Severity:

For Major Bleeding:

• Stop apixaban immediately 1
• Provide local therapy/manual compression if applicable 1
• Provide supportive care and volume resuscitation 1
• Assess for and manage comorbidities that could contribute to bleeding (e.g., thrombocytopenia, uremia, liver disease) 1
• Consider surgical/procedural management of bleeding site 1
• For life-threatening bleeding, consider administering reversal agents such as prothrombin complex concentrates (PCCs) or andexanet alfa (specific reversal agent for apixaban) 1, 2

For Non-Major Bleeding:

• Stop apixaban temporarily 1
• Provide local therapy/manual compression 1
• Provide supportive care and volume resuscitation 1
• Do not administer reversal/hemostatic agents 1
• Assess for and manage comorbidities that could contribute to bleeding 1

Important Considerations

• Apixaban increases the risk of bleeding and can cause serious, potentially fatal bleeding 2
• The anticoagulant effect of apixaban persists for approximately 24 hours after the last dose (about two drug half-lives) 2
• Hemodialysis does not significantly impact apixaban exposure 2
• Protamine sulfate and vitamin K are not expected to affect the anticoagulant activity of apixaban 2

Diagnostic Workup

• Urinalysis to confirm hematuria and assess for infection 3
• Complete blood count to assess hemoglobin levels 1
• Renal function tests (BUN, creatinine) as apixaban-related nephropathy has been reported 4
• Consider urological evaluation as significant pathological findings (carcinoma, calculi, infection, etc.) are often discovered in anticoagulated patients with hematuria 3

Restarting Anticoagulation

Once bleeding is controlled and the patient is stable, consider:

• Is there a clinical indication for continued anticoagulation? 1
• Has the source of bleeding been identified and addressed? 1
• Is the patient at high risk of rebleeding? 1

If it's safe to restart anticoagulation:

• Resume apixaban at least 6 hours after bleeding has been controlled 1
• Consider dose adjustment if appropriate 2
• If apixaban is contraindicated due to the bleeding event, consider alternative anticoagulation options 1

Pitfalls and Caveats

• Avoid premature discontinuation of apixaban without alternative anticoagulation as this increases thrombotic risk 2
• Among anticoagulants, rivaroxaban and warfarin appear to have higher associations with hematuria compared to apixaban 5
• Drug-drug interactions may increase bleeding risk - assess for concomitant medications affecting hemostasis (other anticoagulants, antiplatelets, NSAIDs, SSRIs/SNRIs) 2, 6
• Patients with renal impairment may require dose adjustment of apixaban as kidney dysfunction can increase bleeding risk 7
• Don't assume hematuria is solely due to anticoagulation - underlying urological pathology is common and requires evaluation 3