How to manage a patient with an intradwelling catheter presenting with hematuria while on apixaban (eliquis)?

Management of Hematuria in a Patient with Indwelling Catheter on Apixaban

For patients with an indwelling catheter who develop hematuria while on apixaban, the anticoagulant should be temporarily discontinued until bleeding resolves, as DOACs have been associated with an increased risk of genitourinary tract bleeding and should be used with caution in patients with genitourinary tract lesions, pathology, or instrumentation.

Initial Assessment

• Evaluate the severity of hematuria - determine if it's gross or microscopic hematuria and assess for hemodynamic stability 1
• Check complete blood count to assess for significant blood loss and monitor hemoglobin levels 2
• Consider obtaining renal function tests as apixaban is partially eliminated by the kidneys (27% renal excretion) 1, 3
• Assess for other potential causes of hematuria beyond the catheter-related trauma, such as urinary tract infection, kidney stones, or malignancy 2

Management Algorithm

Step 1: Immediate Management

• Temporarily discontinue apixaban until bleeding resolves 1, 3
• Provide supportive care and volume resuscitation if needed for significant bleeding 2
• Consider catheter irrigation to prevent clot formation and maintain patency 2
• For severe or life-threatening bleeding, consider administering andexanet alfa, a specific reversal agent for apixaban 2, 3

Step 2: Address the Catheter

• Evaluate if catheter replacement is necessary - if the current catheter is causing trauma or is obstructed by clots 2
• Ensure proper catheter fixation to minimize movement and trauma to the urethral mucosa 2

Step 3: Anticoagulation Management

• For patients at high risk of thrombosis, consider bridging with parenteral anticoagulation once bleeding is controlled 1
• For resumption of apixaban after bleeding has stopped:
  • For low bleeding risk: resume apixaban at least six hours after bleeding has resolved 1
  • For high bleeding risk: delay resumption for 24-48 hours after bleeding has resolved 1

Special Considerations

Renal Function

• Monitor renal function closely as apixaban is contraindicated in patients with severe renal impairment (CrCl <25 mL/min) 1
• Acute kidney injury can increase apixaban levels and bleeding risk 4
• Patients with compromised renal function should be monitored more closely with laboratory testing 1

Drug Interactions

• Evaluate for concomitant medications that may increase bleeding risk:
  • Antiplatelet agents (including aspirin)
  • NSAIDs
  • Other drugs affecting hemostasis 3
• Concomitant use of P2Y12 inhibitors significantly increases bleeding risk (odds ratio = 5.9) 4

Common Pitfalls and Caveats

• Avoid restarting apixaban too early after catheter manipulation or replacement, as this increases bleeding risk 1
• Do not rely on standard coagulation tests (INR, aPTT) to monitor apixaban activity, as they do not correlate well with drug levels 5
• Be aware that patients with indwelling catheters are at higher risk for genitourinary bleeding when on anticoagulants 1
• For patients requiring long-term catheterization who need anticoagulation, consider alternative anticoagulants or reduced dosing of apixaban based on bleeding risk assessment 1
• Recognize that apixaban-related bleeding may be more common in patients with acute kidney injury than typically reported in clinical trials 4

Long-term Management

• Once bleeding has resolved and apixaban is resumed, implement regular monitoring for recurrent hematuria 2
• Consider urological evaluation to identify any underlying pathology contributing to bleeding risk 2
• For patients with recurrent catheter-associated hematuria on apixaban, evaluate the necessity of continued anticoagulation versus alternative approaches to thromboprophylaxis 1