Should patients on Eliquis (apixaban) with a history of gastrointestinal (GI) bleed be kept on proton pump inhibitor (PPI) therapy indefinitely?

Should Patients on Eliquis with Prior GI Bleed Continue PPI Indefinitely?

Yes, patients on Eliquis (apixaban) with a history of gastrointestinal bleeding should remain on PPI therapy indefinitely, as they meet high-risk criteria that definitively warrant ongoing gastroprotection.

Risk Stratification for GI Bleeding

Patients with a history of upper GI bleeding who require anticoagulation represent the highest-risk category for recurrent bleeding events. 1 The combination of prior GI bleeding plus anticoagulant therapy creates a multiplicative risk that mandates continued acid suppression. 2

Key risk factors that justify indefinite PPI use include:

• History of upper GI bleeding (the single strongest predictor of recurrence) 1
• Current anticoagulant therapy (Eliquis) 2
• The combination of these two factors places patients in the "definitely indicated for long-term use" category 1

Evidence Supporting Indefinite PPI Therapy

The 2022 AGA Clinical Practice Update explicitly states that patients at high risk for upper GI bleeding should not be considered for PPI de-prescribing. 1 This guideline specifically identifies patients with a history of upper GI bleeding taking anticoagulants as high-risk individuals who require ongoing PPI therapy. 1

Multiple cardiology societies reinforce this recommendation:

• Patients taking anticoagulants with prior GI bleeding history should receive PPIs 2
• The American Heart Association recommends PPIs for patients on anticoagulants with any high-risk factors, particularly prior upper GI bleeding 2
• PPIs markedly reduce the likelihood of upper GI bleeding in patients on antithrombotic therapy 2

Research data demonstrate that long-term PPI therapy reduces recurrent UGIB risk (RR: 0.51), with a recurrence rate of 17.5 per 1000 person-years over 3 years of follow-up. 3 This protective effect persists even in patients taking anticoagulants like warfarin. 3

Definitive Indications Table

According to AGA guidelines, your patient falls into the "definitely indicated for long-term use" category: gastroprotection in users of anticoagulants at high risk for GI bleeding. 1 A history of GI bleeding is the most compelling high-risk factor. 1

Monitoring and Optimization

While indefinite therapy is indicated, optimize the regimen:

• Use once-daily standard-dose PPI rather than twice-daily dosing unless there is documented failure of standard dosing 1
• Document the ongoing indication clearly in the medical record (history of GI bleeding + current anticoagulation) 1
• Reassess periodically only if the anticoagulation is discontinued, at which point de-prescribing could be reconsidered 1

Common Pitfalls to Avoid

Do not attempt de-prescribing in this population. The AGA guideline explicitly warns that patients at high risk for upper GI bleeding should not be considered for PPI de-prescribing due to the sufficiently increased likelihood of future bleeding events. 1 The potential harms of long-term PPI use (C. difficile infection, pneumonia, nutrient malabsorption) are substantially outweighed by the marked reduction in life-threatening GI bleeding risk. 2

Do not substitute H2-receptor antagonists. While H2RAs may be alternatives in some lower-risk scenarios, PPIs have superior efficacy in reducing GI bleeding risk in high-risk patients on anticoagulants. 4, 3

Duration of Therapy

The indication for PPI therapy persists as long as the patient remains on Eliquis. 1, 2 If anticoagulation is discontinued and sufficient time has passed since the prior bleeding event, reassessment for potential de-prescribing could occur, but this would require careful individualized risk-benefit analysis. 1