Should anticoagulation with Enoxaparin (enoxaparin sodium) and Eliquis (apixaban) be held in a patient with penile bleeding, recently diagnosed with a kidney stone, urinary tract infection (UTI), and resolved fecal impaction, presenting with hypotension, bradycardia, and hypoxia?

From the Guidelines

I strongly recommend holding both enoxaparin and apixaban (Eliquis) temporarily due to the active penile bleeding and hypotension, as the patient's current clinical picture suggests a high risk of worsening bleeding with continued anticoagulation. The patient's blood pressure of 86/51 indicates significant hypotension, which combined with active bleeding represents a concerning clinical picture, as noted in the guidelines for the use of pharmacologic prophylaxis in patients undergoing urologic surgery 1. These anticoagulants increase bleeding risk and could worsen the current bleeding. According to the American Society of Clinical Oncology clinical practice guideline update on venous thromboembolism prophylaxis and treatment in patients with cancer, contraindications to therapeutic anticoagulation include active major bleeding at any site, which is consistent with the patient's current condition 1.

Once the bleeding has resolved and blood pressure has normalized (systolic >90 mmHg), anticoagulation can be reassessed. The kidney stone and UTI may be contributing to the urinary tract bleeding, and these conditions should be addressed first. Monitor the patient closely for signs of worsening bleeding or clotting, checking hemoglobin levels regularly. If the patient is on these medications for a high-risk condition like recent venous thromboembolism or mechanical heart valve, consult with the prescribing specialist about alternative management during this acute bleeding episode. Resume anticoagulation only when the benefit clearly outweighs the bleeding risk, taking into consideration the patient's individual risk factors and clinical status, as guided by the most recent and highest quality evidence available 1.

Key considerations in this decision include:

• The patient's current active bleeding and hypotension, which increase the risk of worsening bleeding with continued anticoagulation
• The need to address the underlying conditions contributing to the bleeding, such as the kidney stone and UTI
• The importance of monitoring the patient closely for signs of worsening bleeding or clotting
• The need to consult with the prescribing specialist about alternative management during this acute bleeding episode, if the patient is on these medications for a high-risk condition.

From the FDA Drug Label

The discontinuation rate due to bleeding events was 0.7% in the apixaban-treated patients compared to 1.7% in enoxaparin/warfarin-treated patients in the AMPLIFY study. Adverse reactions related to bleeding occurred in 417 (15.6%) apixaban-treated patients compared to 661 (24.6%) enoxaparin/warfarin-treated patients. Bleeding results from the AMPLIFY study are summarized in Table 5.

Given the patient's recent visit to the ER with a diagnosis of kidney stone, UTI, and resolved fecal impaction, and current presentation of penis bleeding, holding enoxaparin and eliquis should be considered due to the increased risk of bleeding associated with these medications 2. The patient's low blood pressure (BP 86/51) and low oxygen saturation (O2 90% on RA) may also increase the risk of bleeding complications. It is recommended to hold these medications temporarily until the patient's condition stabilizes and the risk of bleeding is reassessed.

From the Research

Patient Status

The patient has recently visited the ER and was diagnosed with a kidney stone, UTI, and resolved fecal impaction. The patient's current vital signs are:

• BP: 86/51
• P: 73
• T: 99.0
• O2: 90% on RA

Medication Considerations

The patient is currently taking enoxaparin and eliquis. Considering the patient's low blood pressure (86/51) and recent diagnosis, it is essential to evaluate the risk of bleeding associated with these medications.

• Enoxaparin is a low-molecular-weight heparin commonly used to prevent and treat thromboembolic disorders 3.
• The use of enoxaparin in patients with end-stage renal disease requires careful consideration, as it may increase the risk of bleeding 4.
• A study comparing the efficacy and safety of direct oral anticoagulants (DOACs) to low-molecular-weight heparin (LMWH) for cancer-associated thromboembolism found no significant difference in major bleeding rates between the groups, although enoxaparin had the highest rate at 8.8% 5.
• Case reports have highlighted the importance of rigorous dose adjustment and monitoring for patients at high risk of hemorrhagic complications, such as the elderly and those with renal function impairment 6.
• A study comparing apixaban to enoxaparin for thromboprophylaxis in medically ill patients found that apixaban was associated with significantly more major bleeding events than enoxaparin 7.

Key Considerations

• The patient's low blood pressure and recent diagnosis of kidney stone, UTI, and resolved fecal impaction may increase the risk of bleeding.
• The use of enoxaparin and eliquis may need to be re-evaluated in light of these factors.
• Close monitoring of the patient's vital signs and laboratory results is crucial to minimize the risk of bleeding complications.

Potential Next Steps

• Consider holding enoxaparin and eliquis temporarily to minimize the risk of bleeding.
• Monitor the patient's vital signs and laboratory results closely.
• Re-evaluate the patient's medication regimen and consider alternative anticoagulation options if necessary.
• Consult with a healthcare professional to determine the best course of action for the patient's specific situation.