Should I stop Eliquis (apixaban) in a patient with benign prostatic hyperplasia (BPH) who has a Foley catheter with bloody output?

Management of Hematuria in BPH Patient on Eliquis with Foley Catheter

Do not stop Eliquis abruptly—temporarily hold the medication, provide supportive care, assess bleeding severity, and coordinate urgent urology follow-up while evaluating thromboembolic risk before making decisions about anticoagulation resumption. 1, 2

Immediate Assessment and Management

Assess Bleeding Severity

• Determine if this is major bleeding by evaluating for: hemodynamic instability (hypotension, tachycardia), hemoglobin drop ≥2 g/dL, need for blood transfusion ≥2 units, or bleeding at a critical anatomical site 1

• For non-life-threatening hematuria (which this appears to be given the patient was ambulatory enough to be sent home from ER): temporarily discontinue Eliquis and provide supportive care with adequate hydration and catheter management 3, 1

• Monitor hemoglobin/hematocrit to quantify blood loss and guide transfusion decisions if needed 1

Anticoagulation Management

• Hold Eliquis temporarily given active bleeding—the FDA label explicitly states to "discontinue apixaban tablets in patients with active pathological hemorrhage" 2

• Understand the pharmacokinetics: Apixaban has a rapid offset of action (approximately 24 hours), with anticoagulant effects persisting for at least 24 hours after the last dose (about two drug half-lives) 3, 2

• Do not use reversal agents (prothrombin complex concentrates, andexanet alfa) unless this becomes life-threatening bleeding with hemodynamic instability—these are reserved for major hemorrhage 1, 2

• Activated charcoal is only useful if the last Eliquis dose was taken within 3 hours, which is unlikely in this scenario 3, 2

Catheter Management Considerations

Foley Catheter and BPH-Related Bleeding

• The bleeding is likely multifactorial: traumatic catheterization in the setting of BPH (enlarged, vascular prostate) combined with anticoagulation 3

• Maintain continuous bladder irrigation (CBI) if clots are present to prevent catheter obstruction—this is standard supportive care for post-catheterization hematuria in BPH patients 3

• The AUA guideline notes that gross hematuria is an uncommon complication of BPH and must be proven to be of prostatic etiology through appropriate evaluation 3

Thromboembolic Risk Assessment

Before Resuming Anticoagulation

• Identify the indication for Eliquis: atrial fibrillation (stroke prevention), venous thromboembolism treatment/prevention, or other indication 2

• Calculate stroke risk if atrial fibrillation: Use CHA₂DS₂-VASc score to determine thromboembolic risk during the period off anticoagulation 1

• The FDA label warns: "If apixaban tablets are discontinued for a reason other than pathological bleeding or completion of therapy, consider coverage with another anticoagulant" to prevent thrombotic events 2

• High-risk patients (CHA₂DS₂-VASc ≥4, recent stroke/TIA, mechanical heart valve, recent VTE) may need bridging anticoagulation discussion with cardiology/hematology, though the bleeding source must be controlled first 3, 1

Timing of Anticoagulation Resumption

When to Restart Eliquis

• Resume Eliquis at least 6 hours after bleeding has been controlled and the patient is hemodynamically stable, per anesthesia guidelines 1

• Ensure the bleeding source is identified and addressed before restarting—in this case, urology evaluation is critical to assess whether surgical intervention for BPH is needed 1

• Consider whether the patient is at high risk of rebleeding: ongoing catheter trauma, large prostate with friable tissue, or inadequate hemostasis may warrant delaying restart 1

• The Asian Pacific gastroenterology guidelines recommend discontinuing DOACs 2 days before high-risk procedures in patients with normal renal function (CrCl >80 mL/min), which provides context for the offset period 3

Urology Coordination

Definitive Management Planning

• Urgent urology follow-up is essential to evaluate for: need for cystoscopy to identify bleeding source, consideration of transurethral resection of prostate (TURP) or other BPH surgical intervention, and assessment of prostate size/pathology 3

• The AUA guideline recommends surgery for patients with recurrent gross hematuria clearly due to BPH and refractory to other therapies 3

• If surgical intervention is planned: DOACs should be discontinued 2 days preoperatively for most urological procedures in patients with normal renal function 3

• Perioperative bridging protocols with low molecular weight heparin (LMWH) are effective for high-risk patients, started 36-48 hours after last warfarin dose (though this patient is on Eliquis, not warfarin), and stopped 24 hours preoperatively 3

Common Pitfalls to Avoid

• Do not abruptly stop Eliquis without a plan: The FDA label emphasizes increased stroke risk with premature discontinuation in atrial fibrillation patients—coordinate with cardiology if needed 2

• Do not use vitamin K, protamine, or FFP: These are ineffective for reversing DOACs like apixaban, which are direct factor Xa inhibitors, not vitamin K antagonists 3, 2

• Do not check PT/INR or aPTT to guide management: These tests do not reliably reflect anticoagulation status with DOACs and are not useful for monitoring 3

• Do not assume the bleeding will resolve with catheter alone: BPH-related hematuria may require definitive surgical management, especially if recurrent 3

• Assess renal function: Apixaban elimination is affected by renal impairment (25% renal elimination), which prolongs drug effects and influences timing decisions 3