Switching to Apixaban After GI Bleeding on Rivaroxaban
For a 77-year-old patient with atrial fibrillation who experienced lower GI bleeding from diverticulosis while on rivaroxaban, switch to apixaban, which has the most favorable bleeding profile among DOACs, particularly for gastrointestinal bleeding. 1
Evidence-Based Rationale
Why Apixaban is the Preferred Alternative
The 2018 CHEST guidelines specifically recommend that in patients with prior gastrointestinal bleeding, apixaban or dabigatran 110 mg bid may be preferable as they are the only NOACs not associated with an increased risk of gastrointestinal bleeding compared with warfarin. 1 This is critical for your patient who has already demonstrated vulnerability to GI bleeding.
Apixaban demonstrates the lowest bleeding risk among all DOACs based on multiple lines of evidence:
- In patients at high risk of bleeding, apixaban shows significantly less major bleeding compared with warfarin 1
- Based on indirect comparisons and cancer-associated thrombosis studies, the risk of bleeding may be lower with apixaban than with other DOACs 1
- Real-world Medicare data showed apixaban had lower bleeding risk than rivaroxaban (HR 0.69,95% CI 0.60-0.79) while maintaining equivalent stroke prevention efficacy 2
The Problem with Rivaroxaban
Rivaroxaban specifically carries higher GI bleeding risk:
- In the ROCKET AF trial, rivaroxaban showed significantly higher rates of major or nonmajor clinical GI bleeding versus warfarin (3.61 vs 2.60 events/100 patient-years; HR 1.42) 3
- GI bleeding may be higher with rivaroxaban than with VKA therapy in atrial fibrillation patients 1
- Real-world evidence confirms rivaroxaban has higher bleeding risk than warfarin, unlike apixaban 2
Efficacy Maintained with Apixaban
Importantly, switching to apixaban does not compromise stroke prevention:
- All NOACs (including apixaban) are more effective than warfarin in preventing stroke (HR 0.86 for apixaban vs warfarin) 2
- There were no differences in effectiveness across NOACs for stroke prevention 2
- The 2018 CHEST guidelines give a strong recommendation for NOACs over VKA in eligible AF patients 1
Practical Implementation
Dosing Considerations
Standard apixaban dosing is 5 mg twice daily, but dose reduction to 2.5 mg twice daily is indicated if the patient meets ≥2 of the following criteria: 1
- Age ≥80 years (your patient is 77, close but doesn't meet this)
- Weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Assess these parameters before initiating therapy.
Addressing Modifiable Bleeding Risk Factors
Before restarting any anticoagulation, address the following to minimize recurrent bleeding: 1
- Ensure the diverticulosis has been adequately evaluated and any actively bleeding source treated
- Control blood pressure if hypertensive (reduces bleeding risk) 1
- Consider proton pump inhibitor (PPI) therapy to minimize upper GI bleeding risk 1
- Avoid concomitant antiplatelet therapy unless absolutely necessary for another indication 1
- Counsel on alcohol avoidance 1
Common Pitfalls to Avoid
Do not use dabigatran 150 mg bid in this patient - while dabigatran 110 mg bid (not available in the US) has favorable GI bleeding profile similar to apixaban, the 150 mg dose available in the US is associated with increased GI bleeding 1
Do not continue rivaroxaban - the evidence clearly shows higher GI bleeding rates with rivaroxaban compared to other options 3
Do not avoid anticoagulation entirely - the stroke risk from untreated AF likely outweighs bleeding risk once the acute bleed is managed and modifiable factors addressed 1
Timing of Reinitiation
Reinitiation of OAC after a bleeding event should be considered by a multidisciplinary team, but anticoagulation is generally appropriate once the bleeding source is controlled and contributing factors are managed. 1 For lower GI bleeding from diverticulosis, this typically means ensuring hemodynamic stability, resolution of active bleeding, and appropriate hemoglobin recovery.