Should I hold Eliquis (apixaban) for a patient with Benign Prostatic Hyperplasia (BPH) who experienced spontaneous bleeding after a straight catheterization procedure?

Management of Eliquis in BPH Patient with Post-Catheterization Bleeding

Yes, you should hold Eliquis immediately in this patient with active spontaneous bleeding following urological catheterization, and it should remain held until hemostasis is definitively achieved and the bleeding risk has substantially decreased. 1

Immediate Management of Active Bleeding

Hold Eliquis now and do not resume until bleeding is controlled. The FDA label for apixaban explicitly states to "discontinue apixaban tablets in patients with active pathological hemorrhage" 1. This patient has active spontaneous bleeding requiring emergency intervention and continuous bladder irrigation via three-way catheter, which clearly qualifies as active pathological hemorrhage.

Bleeding Control Considerations

• The pharmacodynamic effect of apixaban persists for at least 24 hours after the last dose (approximately two drug half-lives), so the anticoagulant effect will gradually diminish over this timeframe 1
• Consider reversal with andexanet alfa if bleeding is life-threatening or uncontrolled despite supportive measures 1
• Prothrombin complex concentrate (PCC), activated PCC, or recombinant factor VIIa may be considered, though they have not been evaluated in clinical studies for apixaban reversal 1
• Do not use PT, INR, aPTT, or anti-Xa levels to monitor reversal effectiveness - these tests are not useful for guiding management when PCCs are used 1

Assessment Before Resumption

Before restarting Eliquis, you must carefully evaluate:

• Adequacy of hemostasis at the catheter site and bladder - there should be no ongoing hematuria and the three-way catheter irrigation should be clear 2
• Hemoglobin stability - serial measurements should show no ongoing blood loss 3
• Absence of clot retention or need for ongoing bladder irrigation 4
• Patient's renal function - this affects both bleeding risk and apixaban clearance 3, 1

Timing of Anticoagulation Resumption

For genitourinary procedures with bleeding complications, delay resumption of full-dose anticoagulation for 24-72 hours postoperatively or until complete hemostasis is confirmed 3. The specific timing depends on:

• Low bleeding risk with adequate hemostasis: Resume at least 6 hours after bleeding cessation 3
• Higher bleeding risk or incomplete hemostasis: Delay therapeutic anticoagulation for 24-72 hours 3
• Ongoing bleeding or surgical contraindication: Keep Eliquis held and consider venous thromboprophylaxis with lower-intensity anticoagulation 3

Balancing Thrombotic Risk

While holding anticoagulation, assess the patient's thrombotic risk:

• If the indication for Eliquis is atrial fibrillation: Stopping increases stroke risk, but this must be balanced against life-threatening bleeding 1
• The FDA label warns that discontinuation for reasons other than pathological bleeding increases thrombotic risk - however, active bleeding IS pathological bleeding and justifies holding the medication 1
• Consider bridging only in very high-risk patients (e.g., recent stroke, high CHA2DS2-VASc score), though bridging with heparin products increases bleeding risk 2, 3

Common Pitfalls to Avoid

• Do not resume Eliquis while the three-way catheter is still irrigating for active bleeding - this will perpetuate hemorrhage 3
• Do not use bridging anticoagulation routinely - this increases bleeding risk without proven benefit in most situations 2, 3
• Do not rely on coagulation tests (PT/INR) to determine when it's safe to resume - these are unreliable for apixaban 1
• Do not forget to reassess renal function - post-procedure changes in kidney function affect apixaban dosing and bleeding risk 3, 1

Coordination with Urology and Cardiology

Collaborate with urology to determine when hemostasis is adequate and with the prescribing cardiologist/neurologist regarding the thrombotic risk of holding anticoagulation 2. The decision to restart should be made jointly, weighing the patient's specific bleeding versus thrombotic risk profile.