Can a patient resume taking Eliquis (apixaban) for atrial fibrillation after a one-month interruption?

Resuming Eliquis After One-Month Interruption in Atrial Fibrillation

Yes, the patient should resume Eliquis (apixaban) immediately for atrial fibrillation after the one-month interruption, as the stroke prevention benefit outweighs bleeding risk in patients with ongoing AF indications, and no bridging anticoagulation is needed due to apixaban's rapid onset of action. 1

Immediate Resumption is Appropriate

• The patient can restart apixaban at the next scheduled dose without any special precautions or bridging therapy, as the medication achieves therapeutic anticoagulation promptly after administration 1
• The FDA label explicitly states that when switching from other anticoagulants to apixaban or restarting therapy, patients should "begin taking apixaban at the usual time of the next dose" 1
• There is no requirement for dose adjustment or gradual titration when resuming apixaban after interruption 1

Stroke Risk During Interruption

• The one-month gap in anticoagulation has placed this patient at significantly elevated stroke risk, with atrial fibrillation increasing stroke risk by 2.5-fold compared to patients without AF 2
• The 2020 ACC Expert Consensus emphasizes that patients with ongoing indications for anticoagulation should restart therapy "when the concern for additional bleeding complications has resolved" 3
• For patients with atrial fibrillation and no contraindications, continuing anticoagulation interruption increases mortality and morbidity from thromboembolic events 3

Dosing Considerations Upon Restart

• Resume at the appropriate dose based on current patient characteristics: 5 mg twice daily for most patients, or 2.5 mg twice daily if the patient meets at least 2 of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1
• Verify current renal function before restarting, as apixaban dosing depends on kidney function and other patient factors 1, 4
• If the patient was previously on 2.5 mg twice daily and met dose-reduction criteria, continue that dose; if on 5 mg twice daily without dose-reduction criteria, resume at 5 mg twice daily 1, 5

No Bridging Required

• Bridging anticoagulation with heparin or low molecular weight heparin is NOT indicated when restarting apixaban after interruption in atrial fibrillation patients 6
• The ACC guidelines specifically state that bridging is only indicated for patients with recent (<3 months) venous thromboembolism or pulmonary embolism, not for routine atrial fibrillation 6
• Apixaban's rapid onset eliminates the need for parenteral anticoagulation overlap that is required with warfarin 1

Critical Safety Assessment Before Restart

• Confirm there is no active bleeding or recent major bleeding event that caused the interruption, as the 2020 ACC guidelines recommend ensuring "hemostasis has been achieved and the patient is clinically stable" before restarting 3
• Evaluate whether any high-risk bleeding conditions have developed during the month off anticoagulation, such as new intracranial hemorrhage, gastrointestinal bleeding source, or planned invasive procedures 3
• If the interruption was due to bleeding rather than simply running out of medication, assess whether the bleeding source has been identified and treated before resuming 3

Timing Considerations if Bleeding Occurred

• If the patient had experienced bleeding that prompted discontinuation (rather than simply running out), the 2020 ACC guidelines suggest restarting anticoagulation can occur within 1-3 days for most patients once hemostasis is achieved 3
• For intracranial hemorrhage specifically, the AHA/ASA guidelines suggest considering a delay of at least 4-10 weeks before resuming anticoagulation, though this must be balanced against thrombotic risk 3
• However, if the patient simply ran out of medication without any bleeding event, immediate resumption is appropriate and recommended 1

Monitoring After Restart

• No routine laboratory monitoring is required when restarting apixaban, unlike warfarin which requires INR monitoring 1
• Counsel the patient on adherence and the importance of not missing doses, as the short half-life of apixaban (approximately 12 hours) means that missed doses quickly result in loss of anticoagulation effect 1
• If a dose is missed, the FDA label instructs patients to "take the dose as soon as possible on the same day and resume twice-daily administration" without doubling the dose 1

Common Pitfall to Avoid

• Do not delay restart waiting for "bridging" or laboratory tests in a patient who simply ran out of medication and has no contraindications—this unnecessarily prolongs the period of elevated stroke risk 6, 1
• Do not reduce the dose unnecessarily; only use 2.5 mg twice daily if the patient meets the specific dose-reduction criteria outlined in the FDA label 1, 5