What is the appropriate thromboprophylaxis if there are concerns about ongoing bleeding and the need to postpone Eliquis (apixaban)?

Appropriate Thromboprophylaxis When Postponing Apixaban Due to Bleeding Concerns

When apixaban (Eliquis) must be postponed due to concerns about ongoing bleeding, mechanical thromboprophylaxis with intermittent pneumatic compression (IPC) should be initiated immediately, followed by pharmacological thromboprophylaxis with low molecular weight heparin (LMWH) or unfractionated heparin (UFH) once bleeding is controlled. 1

Initial Management During Active Bleeding

• Mechanical thromboprophylaxis with IPC and/or anti-embolic stockings should be started as soon as possible while apixaban is held due to bleeding concerns 1
• Do not use graduated compression stockings alone as they have not shown reduction in DVT rates in trauma patients 1
• Avoid inferior vena cava filters as routine thromboprophylaxis as they are not recommended unless anticoagulation is absolutely contraindicated for an extended period 1

Resumption of Pharmacological Prophylaxis

• Initiate pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled 1
• For patients with high bleeding risk, consider the following options:
  • Low molecular weight heparin (LMWH) at prophylactic dose once hemostasis is achieved 1
  • Unfractionated heparin (UFH) 5,000 units subcutaneously three times daily or twice daily if there are renal concerns 2, 3
  • Fondaparinux can be considered as an alternative if heparins are contraindicated 1, 4

Timing of Resumption of Full Anticoagulation with Apixaban

• Resume apixaban only when adequate surgical hemostasis has been established 5
• For procedures with high bleeding risk, wait at least 24-72 hours after bleeding is controlled before restarting therapeutic anticoagulation 1, 6
• When restarting apixaban after bleeding control:
  • For once-daily regimen: resume the next morning if morning dose, or evening of next day if evening dose 1, 6
  • For twice-daily regimen: resume the next day, not the same day as the procedure/bleeding event 1, 6

Special Considerations

• For patients with renal insufficiency (CrCl 15-30 mL/min), consider using adjusted doses of LMWH or UFH rather than fondaparinux 4
• Avoid apixaban in patients with severe renal impairment (CrCl <15 mL/min) 7, 5
• Monitor renal function regularly as surgical procedures and medical conditions may affect kidney function and alter drug clearance 7, 6
• For patients with cancer, LMWH is preferred for thromboprophylaxis when apixaban must be postponed 1

Transitioning Back to Apixaban

• When transitioning from prophylactic LMWH/UFH back to apixaban:
  • Discontinue the heparin and begin taking apixaban at the usual time of the next dose of heparin 5
  • No bridging is required when transitioning from prophylactic doses of heparin to apixaban 1, 5
• For patients previously on therapeutic apixaban for atrial fibrillation or VTE treatment, resume the appropriate dose based on the indication and patient characteristics 5

Common Pitfalls to Avoid

• Do not delay mechanical prophylaxis while waiting for bleeding to resolve; implement IPC immediately 1
• Avoid bridging with heparin when stopping or restarting apixaban except in very high thrombotic risk patients 1, 7
• Do not use pharmacological prophylaxis if active bleeding is present; wait until hemostasis is achieved 1
• Avoid concomitant use of apixaban with drugs that are strong inhibitors of both CYP3A4 and P-glycoprotein when restarting anticoagulation 5