From the Guidelines
For a hemodynamically stable episode of gross hematuria without anemia in a patient on Eliquis (apixaban), it is recommended to hold the medication for at least 24 hours after the bleeding has resolved, based on the patient's creatinine clearance (CrCl) and bleeding risk. According to the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1, the suggested duration for withholding DOACs like apixaban is 24 hours for patients with a CrCl of 80 mL/min or higher and low bleeding risk.
- Key factors influencing the decision to hold Eliquis include:
- The patient's renal function, as measured by CrCl
- The severity and risk of the bleeding episode
- The patient's individual thrombotic risk versus bleeding risk
- For patients with uncertain, intermediate, or high bleeding risk, a longer interruption period of 48 hours may be considered, as suggested by the guidelines 1.
- It is essential to individualize the decision based on the patient's specific clinical context, including their thrombotic risk factors and the underlying cause of the hematuria.
- Close monitoring for both recurrent bleeding and thrombotic events is crucial during the temporary discontinuation of Eliquis.
- Before restarting Eliquis, it's important to investigate and address the underlying cause of the hematuria, which could include urinary tract infection, kidney stones, or malignancy, to minimize the risk of recurrence.
From the Research
Holding Eliquis After Hemodynamically Stable Episode of Gross Hematuria
- There is no direct evidence on how long to hold Eliquis (apixaban) after a hemodynamically stable episode of gross hematuria without anemia.
- A study on apixaban versus warfarin for acute venous thromboembolism in patients with end-stage kidney disease found that apixaban was associated with a lower risk of major bleeding 2.
- Another study on the risk of major bleeding with apixaban administration in patients with acute kidney injury found that apixaban use in the AKI group resulted in a higher than normally reported incidence of apixaban-associated major bleeding 3.
- A study on macroscopic hematuria in patients on anticoagulation therapy suggested that the risk of urological etiology of hematuria is lower in patients on oral anticoagulants, especially when INR >4 4.
- However, there is no specific guidance on holding Eliquis after a hemodynamically stable episode of gross hematuria without anemia, and the decision to hold or resume anticoagulation therapy should be made on a case-by-case basis, considering the individual patient's risk factors and medical history.
Considerations for Holding Eliquis
- The risk of thromboembolic events versus the risk of bleeding should be carefully weighed when deciding whether to hold or resume Eliquis 2, 3.
- Patients with a history of gross hematuria may require closer monitoring and follow-up to detect any potential bleeding complications 4, 5.
- The use of Eliquis in patients with acute kidney injury or end-stage kidney disease requires cautious consideration of the potential risks and benefits 2, 3.