Does an elderly patient on apixaban (apixaban) with a prior history of subdural hemorrhage due to head trauma have an increased risk of recurrent subdural hemorrhage?

From the Guidelines

Elderly patients on apixaban with a prior history of subdural hemorrhage following head trauma do have an increased risk of recurrent subdural hemorrhage, but the benefit of anticoagulation often outweighs this risk, as demonstrated by a Markov decision analytic model which showed that a patient would have to fall 295 times for the risk of subdural hematoma to outweigh the benefit of anticoagulation with VKA, and this 'number needed to fall' would be even higher with NOACs like apixaban 1. When considering the risk of recurrent subdural hemorrhage in an elderly patient on apixaban, several factors come into play, including the patient's frailty, risk of falls, and the overall benefit of anticoagulation therapy.

• The risk of falling can be estimated using simple or more sophisticated tools, and the effect of NOACs vs VKA in patients at risk of falling has been analyzed in trials such as ENGAGE-AF TIMI 48 and ARISTOTLE, which showed that the treatment effect of NOACs was consistent in patients at increased vs. not at increased risk of falling 1.
• Frailty per se should not be an exclusion criterion to anticoagulate, as frail and older patients are at an increased risk of stroke and have been shown to benefit from OAC, with the benefit of NOACs over VKA best demonstrated for edoxaban and apixaban in this patient population 1.
• To minimize the risk of recurrent subdural hemorrhage, careful risk-benefit assessment should be performed, and alternatives like left atrial appendage closure for atrial fibrillation patients or lower doses of apixaban (2.5mg twice daily instead of 5mg twice daily) should be considered if appropriate.
• Regular monitoring for neurological symptoms, patient education about fall prevention, and minimizing other bleeding risk factors (such as concomitant antiplatelet therapy or NSAIDs) are essential, with extra vigilance during the first year after the initial subdural hemorrhage when the recurrence risk is highest.

From the Research

Risk of Recurrent Subdural Hemorrhage in Elderly Patients on Apixaban

• The risk of recurrent subdural hemorrhage in elderly patients on apixaban with a prior history of subdural hemorrhage due to head trauma is a concern, as apixaban is known to pose a risk of spontaneous bleeding 2, 3, 4.
• Studies have shown that apixaban, although considered safer than other non-vitamin K dependent oral anticoagulants, can still cause subdural hemorrhage in elderly patients 2, 4.
• The management of apixaban-associated subdural hematoma can be challenging, and the use of factor eight inhibitor bypassing activity has been reported as a viable option for reversal in life-threatening bleeding cases 3.
• Elderly patients on anticoagulation therapy, including apixaban, have an increased risk of bleeding due to age and co-morbidities, which necessitates careful consideration of the benefits and risks of anticoagulation therapy 5.
• Prescribing practices for apixaban in the elderly should be evaluated to ensure appropriate dosing, as incorrect dosing can lead to decreased effectiveness of the medication or increased risk of bleeding 6.

Factors to Consider

• Age and co-morbidities of the patient
• Prior history of subdural hemorrhage due to head trauma
• Current dose and indication for apixaban
• Renal function and body weight of the patient
• Potential for drug interactions with other medications

Relevance of Apixaban

• Apixaban is a factor Xa inhibitor with a lower risk of intracranial bleeding compared to other anticoagulants
• However, it can still cause subdural hemorrhage, especially in elderly patients with a prior history of head trauma 2, 3, 4