Should I discontinue apixaban (eliquis) for a patient transitioning to comfort care?

Discontinuing Apixaban for Patients Transitioning to Comfort Care

Yes, apixaban should be discontinued when transitioning a patient to comfort care as anticoagulation no longer provides benefit and may increase bleeding risk in this setting.

Rationale for Discontinuation

• Anticoagulation therapy is primarily indicated to reduce the risk of thromboembolism and stroke, which are concerns related to long-term morbidity and mortality 1
• For patients transitioning to comfort care, the focus shifts to symptom management and quality of life rather than prevention of future events 1
• Continuing anticoagulation provides no meaningful benefit to comfort or symptom management in end-of-life care 1
• Apixaban carries an ongoing risk of bleeding complications that could negatively impact quality of life in the comfort care setting 1, 2

Clinical Considerations

• Apixaban has a relatively short half-life (approximately 12 hours), allowing for rapid clearance after discontinuation 1, 3
• After discontinuation, apixaban levels decrease to clinically insignificant levels within 48-72 hours in most patients 3
• Unlike warfarin, apixaban does not require a reversal agent for discontinuation in the comfort care setting 1
• The risk of thrombotic events after discontinuation is not a primary concern in comfort care patients where the goal is symptom management rather than prevention of future events 1

Bleeding Risk Considerations

• Even in comfort care settings, bleeding events can cause distressing symptoms:
  • Gastrointestinal bleeding can cause pain, nausea, and distress 1, 2
  • Intracranial bleeding can cause headache, altered mental status, and neurological symptoms 1
• Apixaban is associated with lower rates of intracranial hemorrhage compared to warfarin (0.33% vs 0.80%), but the risk is still present 1
• Gastrointestinal bleeding risk varies by agent but remains a concern with apixaban (0.76% annual risk) 1

Practical Approach to Discontinuation

• Simply stop apixaban without the need for tapering or bridging therapy 1
• No laboratory monitoring is required to confirm clearance 1
• The anticoagulant effect will diminish progressively over 2-3 days 3
• Document the rationale for discontinuation in the medical record, noting the transition to comfort care 1

Special Considerations

• If the patient has a mechanical heart valve (rare with apixaban use), consultation with cardiology may be appropriate, though comfort care goals would still typically favor discontinuation 1
• For patients with recent acute thrombotic events (within 30 days), discontinuation is still appropriate in the comfort care setting, as symptom management takes priority over prevention of recurrent events 1, 4
• If the patient has distressing symptoms potentially related to thrombosis (e.g., severe dyspnea from pulmonary embolism), palliative approaches focusing directly on symptom relief are preferred over continuing anticoagulation 1

Conclusion

When transitioning a patient to comfort care, discontinuing apixaban aligns with the goals of care by eliminating unnecessary medications and reducing the risk of bleeding complications that could impact quality of life. The focus should shift to direct symptom management rather than preventive therapies.