When can Eliquis (apixaban) be restarted in a patient with frequent falls?

Restarting Eliquis in Patients with Frequent Falls

In patients with frequent falls who require anticoagulation, Eliquis (apixaban) should generally be continued or restarted based on their thrombotic risk rather than fall risk alone, as patients would need to fall over 45-458 times per year before the bleeding risk outweighs the stroke prevention benefit. 1

Risk-Benefit Analysis in Fall-Prone Patients

The decision to restart anticoagulation should prioritize the patient's thrombotic risk over fall risk. 2 The 2020 ACC Expert Consensus provides a structured approach:

High Thrombotic Risk Indications (Favor Restarting)

Patients with the following conditions benefit from anticoagulation even with high rebleeding risk 2:

• Atrial fibrillation with CHA₂DS₂-VASc score ≥4 (annual stroke risk 2.8%-5.4%)
• Recent stroke/TIA within 3 months
• Mechanical heart valves (especially mitral position)
• Venous thromboembolism within 3 months
• History of unprovoked or recurrent VTE
• Left atrial or ventricular thrombus

Evidence Supporting Anticoagulation Despite Falls

Apixaban demonstrates superior safety compared to warfarin in patients with fall history. 3 In the ARISTOTLE trial analysis:

• Patients with fall history had higher major bleeding rates (adjusted HR 1.39) but no differential effect between apixaban and warfarin 3
• Subdural bleeding occurred in 5 warfarin patients vs 0 apixaban patients among those with fall history 3
• Apixaban maintained consistent efficacy and safety regardless of fall history 3

Quality-adjusted life-years (QALYs) favor anticoagulation even in high fall-risk patients. 1 Markov analysis demonstrates that older adults (≥75 years) with atrial fibrillation achieve maximum QALYs with apixaban (11.56) compared to no anticoagulation (8.03), and would need to fall 458 times per year for apixaban's benefit to drop below aspirin 1.

Timing of Restart After Bleeding Event

If Major Bleeding Has Occurred

Once hemostasis is achieved and the patient is clinically stable, restart anticoagulation based on thrombotic risk. 2

For high thrombotic risk patients: 2

• Consider parenteral anticoagulation (unfractionated heparin) within 1-3 days with close monitoring
• Transition to apixaban once bleeding source is controlled
• Apixaban can be resumed at least 6 hours after bleeding is controlled 4

Delay restart if: 2

• Bleeding occurred at a critical site (intracranial, spinal, intraocular, pericardial, retroperitoneal)
• Source of bleeding not yet identified
• Patient at high risk of death/disability with rebleeding
• Surgical/invasive procedures planned

If No Recent Bleeding

Continue apixaban without interruption in patients with appropriate indications, even with frequent falls. 3, 1 The mortality and stroke prevention benefits outweigh fall-related bleeding risks 3.

Practical Management Strategies

Risk Mitigation Approaches

Implement fall prevention measures rather than withholding anticoagulation: 2

• Review and minimize medications that increase fall risk (benzodiazepines, antidepressants, vestibular suppressants) 2
• Address polypharmacy, as multiple medications independently increase fall risk 2
• Ensure appropriate apixaban dosing (2.5 mg twice daily if ≥2 criteria: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL) 5

Multidisciplinary Decision-Making

All decisions regarding anticoagulation restart should involve a multidisciplinary care team. 2 This is particularly important when balancing high thrombotic risk against high rebleeding risk.

Common Pitfalls to Avoid

Do not discontinue anticoagulation based solely on fall risk. 3, 1 This common practice is not supported by evidence and increases stroke risk substantially.

Do not assume warfarin and apixaban have equivalent safety profiles in fall-prone patients. 3 Apixaban demonstrates superior safety, particularly for intracranial bleeding.

Do not restart anticoagulation prematurely after intracranial hemorrhage. 6 Limited data suggest waiting 7-10 days in selected patients after ICH, though this requires careful individualized assessment 6.

Contraindications to Restart

Consider permanent discontinuation only if: 2

• Nonvalvular AF with CHA₂DS₂-VASc score <2 (men) or <3 (women)
• Temporary indication completed (e.g., post-surgical prophylaxis)
• First-time provoked VTE >3 months ago
• Patient declines after informed discussion