From the Guidelines
The patient's anticoagulation with Eliquis should be immediately discontinued due to her critically low platelet count of 4,000/μL and severe anemia (hemoglobin 6 g/dL, hematocrit 17.1%). According to the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1, the patient's bleeding is considered major due to the significant decrease in hemoglobin level. The guidelines suggest stopping oral anticoagulants (OAC) and initiating appropriate measures to control bleeding in such cases.
The patient's severe thrombocytopenia and anemia put her at a high risk of bleeding, and the benefits of anticoagulation for atrial fibrillation are outweighed by the risk of bleeding complications in this context. Urgent platelet transfusion is needed to target a platelet count above 20,000/μL, along with packed red blood cell transfusion to address the anemia, as suggested by the guidelines for managing bleeding in patients on OAC 1.
Key considerations in managing this patient's anticoagulation include:
- The patient's history of hematologic malignancy (AML) and solid tumors, which increases her risk of bleeding complications
- The need for close monitoring for bleeding complications, particularly given her severe thrombocytopenia and anemia
- The potential for temporary bridging with a heparin drip once platelets are above 20,000-30,000/μL, as it has a shorter half-life and can be quickly reversed, although this should be done with caution and careful consideration of the patient's individual risk factors.
Once the patient's platelet count recovers above 50,000/μL and bleeding risk decreases, a hematology consultation should be obtained to determine if and when anticoagulation can be safely resumed, potentially at a reduced dose or with a different agent, taking into account the patient's individual risk factors and the guidelines for managing bleeding in patients on OAC 1.
From the FDA Drug Label
Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] Active pathological bleeding [see Warnings and Precautions (5. 2) and Adverse Reactions(6.1)]
The patient has a low platelet level of 4 and severe anemia (hemoglobin 6, hct 17.1), which indicates a high risk of bleeding. Given this information, apixaban (Eliquis) should be discontinued due to the increased risk of bleeding. The patient's condition suggests active pathological bleeding, which is a contraindication for apixaban. 2
From the Research
Anticoagulation Management
The patient's current anticoagulation regimen with Eliquis (apixaban) may need to be reassessed given her severe thrombocytopenia (platelet level of 4) and anemia (hemoglobin 6, hematocrit 17.1) 3.
Platelet Count and Anticoagulation
- A platelet count of less than 30×10^9/L is generally considered a contraindication for full-dose anticoagulation therapy, and a 50% dose reduction is recommended for platelet counts between 30-50×10^9/L 4.
- However, the patient's platelet count is significantly lower than this threshold, which increases the risk of bleeding complications with anticoagulation therapy.
- The use of apixaban, a direct factor Xa inhibitor, may be effective in preventing thromboembolism, but its safety in patients with severe thrombocytopenia is not well established 5.
Considerations for Anticoagulant Therapy
- The patient's history of atrial fibrillation and cervical/colon cancer increases her risk of thromboembolism, but her current platelet count and anemia may necessitate a temporary discontinuation or dose reduction of anticoagulant therapy 6, 7.
- Alternative strategies, such as the use of inferior vena cava (IVC) filters or platelet transfusions, may be considered to mitigate the risk of bleeding complications 4, 3.