What is the duration for holding Eliquis (apixaban) in a patient with a gastrointestinal (GI) bleed?

Duration of Holding Eliquis (Apixaban) in GI Bleeding

For patients with GI bleeding on Eliquis (apixaban), discontinue the medication immediately and restart between 3-7 days after hemostasis is achieved, with the specific timing determined by thrombotic risk stratification.

Immediate Management

• Discontinue apixaban immediately upon presentation with acute GI bleeding, as DOACs should be interrupted at presentation 1, 2
• The anticoagulant effect will dissipate within 24-48 hours due to apixaban's short half-life, making simple discontinuation usually sufficient 1
• For life-threatening hemorrhage, consider specific reversal with andexanet alfa, though routine use is not recommended for most cases 1, 2
• Do not routinely administer prothrombin complex concentrate (PCC) for DOAC-associated bleeding 2, 3

Timing of Apixaban Resumption

Low Thrombotic Risk Patients

• Resume apixaban at 7 days after hemostasis is confirmed for patients with low thrombotic risk (e.g., non-valvular atrial fibrillation with lower CHA2DS2-VASc scores) 1, 2
• Starting before 7 days results in a twofold increase in rebleeding without significant reduction in thromboembolism 1, 4
• Resumption between 7-15 days provides optimal balance, reducing thromboembolic events and mortality without increasing rebleeding 1, 5

High Thrombotic Risk Patients

• Resume apixaban by day 3 once adequate hemostasis is achieved for patients at high thrombotic risk 1
• High-risk conditions include: prosthetic metal heart valve in mitral position, atrial fibrillation with prosthetic heart valve or mitral stenosis, or <3 months after venous thromboembolism 1, 4, 2
• For these patients, consider low molecular weight heparin bridging at 48 hours after hemostasis if apixaban cannot be resumed immediately 1, 4, 2
• Do not use heparin bridging for low thrombotic risk patients, as this increases bleeding without reducing thrombosis 1

Risk Stratification Framework

Assess Thrombotic Risk

• High risk: Mechanical mitral valve, AF with prosthetic valve, recent VTE (<3 months), recent stroke 1, 4, 2
• Moderate risk: AF with CHA2DS2-VASc ≥2, remote VTE (>3 months) 1
• Low risk: AF with CHA2DS2-VASc <2, primary prevention only 1

Assess Rebleeding Risk

• Confirm endoscopic hemostasis before resumption 1, 3
• Identify and treat underlying bleeding source (diverticular disease, vascular ectasias, malignancy) 2
• Consider prophylactic proton pump inhibitor to reduce GI bleeding risk upon resumption 1

Critical Timing Considerations

• Apixaban has rapid onset: Full anticoagulant activity occurs within 3 hours of first dose, making timing of resumption critical 1
• Optimal window for upper GI bleeding: Modeling studies suggest resuming apixaban at 21-47 days produces >99.9% of peak utility, with optimal timing at 32 days 6
• Practical guideline recommendation: Resume at 3-7 days based on thrombotic risk, as this balances real-world clinical needs 1, 2

Common Pitfalls to Avoid

• Do not resume before 48 hours in any patient, as this dramatically increases rebleeding risk 4
• Do not delay beyond 7 days in high-risk patients, as thrombotic events and mortality increase significantly 1
• Do not use heparin bridging routinely, as this is only indicated for highest-risk patients and increases bleeding 1
• Do not give fresh frozen plasma, vitamin K, or routine PCC for apixaban-associated bleeding, as these are ineffective 1, 3

Apixaban-Specific Advantages

• Apixaban demonstrates the lowest risk of GI bleeding among DOACs compared to rivaroxaban and dabigatran 5
• Consider preferentially selecting apixaban when restarting DOAC therapy after GI bleeding 5
• Reduced-dose apixaban (2.5 mg twice daily) may be considered for extended-phase therapy in appropriate patients 1