How to manage a 50yo female with CVA history, on Eliquis (Apixaban), with thrombocytosis, dizziness, iron deficiency anemia from menorrhagia, elevated LFTs, Hepatitis C history, substance use history, intolerant to oral iron, and on Rosuvastatin?

Management of Complex Case: CVA History, Anticoagulation, Iron Deficiency Anemia, and Hepatic Dysfunction

Immediate Priority: Address Iron Deficiency Anemia with Intravenous Iron

Given oral iron intolerance, intravenous iron is the definitive treatment for this patient's iron deficiency anemia, which will simultaneously address both the anemia and the paradoxical thrombocytosis. 1, 2

Understanding the Thrombocytosis-Anemia Connection

• The elevated platelet count is likely reactive thrombocytosis secondary to severe iron deficiency anemia from menorrhagia, not a primary hematologic disorder. 3, 4, 2
• Iron deficiency anemia commonly causes thrombocytosis (elevated platelets), though severe cases can paradoxically present with thrombocytopenia. 3, 2
• The thrombocytosis in iron deficiency typically resolves with iron repletion and does not require separate treatment. 4, 2
• This reactive thrombocytosis may have contributed to her prior CVA, as iron deficiency with thrombocytosis increases thrombotic risk. 5

Iron Replacement Strategy

Intravenous Iron Administration

Since the patient is intolerant to oral iron, intravenous iron is indicated and will provide rapid correction of iron stores. 1

• Intravenous iron should be considered when there is intolerance to at least two different oral iron preparations, which this patient has demonstrated. 1
• For patients intolerant of oral iron, pulses of intravenous iron supplementation should be used instead. 6
• Monitor hemoglobin every 2 weeks initially; expect at least a 10 g/L rise after 2 weeks of adequate iron therapy. 7

Monitoring Parameters

• Check complete blood count with platelet count every 2-4 weeks during iron repletion. 3, 2
• Monitor ferritin and transferrin saturation to confirm adequate iron stores (target ferritin >100 ng/mL, transferrin saturation >20%). 6
• The thrombocytosis should normalize as iron stores are replenished, typically within 2 months. 3, 2

Anticoagulation Management with Eliquis (Apixaban)

Continue Apixaban for Stroke Prevention

Apixaban should be continued at the current dose for secondary stroke prevention, as premature discontinuation increases thrombotic risk. 8

• Premature discontinuation of apixaban in the absence of adequate alternative anticoagulation increases the risk of thrombotic events and stroke. 8
• The standard dose for stroke prevention in atrial fibrillation or post-CVA is 5 mg twice daily, unless dose reduction criteria are met (age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL—requires at least 2 of these factors for 2.5 mg twice daily dosing). 8

Bleeding Risk Considerations

• While apixaban increases bleeding risk, the menorrhagia is the primary source of blood loss and iron deficiency, not anticoagulation-induced bleeding. 8
• Address the menorrhagia directly through gynecologic evaluation and management (hormonal therapy, endometrial ablation, or other interventions as appropriate). 1
• Monitor for signs of pathological bleeding, which would require apixaban discontinuation. 8

Hepatic Considerations

Rosuvastatin and Elevated LFTs

Rosuvastatin should be temporarily discontinued or dose-reduced given elevated LFTs in the context of hepatitis C history and substance use. 6

• Elevated LFTs require investigation for the underlying cause: hepatitis C reactivation, alcohol-related liver disease, non-alcoholic fatty liver disease, or drug-induced liver injury. 6
• Check hepatitis C viral load, hepatic function panel, and consider hepatology consultation if LFTs are significantly elevated (>3x upper limit of normal). 6
• Rosuvastatin can cause hepatitis and has been rarely associated with thrombocytopenia, though the thrombocytosis here is more consistent with iron deficiency. 9

Liver Disease and Iron Management

• In patients with hepatitis C and elevated LFTs, iron supplementation should proceed cautiously but is not contraindicated. 6
• Avoid excessive iron loading in chronic liver disease; monitor ferritin closely and target normal ranges (100-300 ng/mL). 6
• Alcohol excess suppresses hepcidin and increases iron absorption; counsel on alcohol avoidance given substance use history. 6

Dizziness Evaluation

Multifactorial Etiology

The dizziness likely stems from:

• Anemia-related decreased oxygen delivery to the brain (hemoglobin likely <10 g/dL given severe iron deficiency). 6
• Potential cerebrovascular insufficiency given CVA history. 5
• Rule out orthostatic hypotension, medication effects, or recurrent cerebrovascular events with focused neurologic examination. 6

Expected Improvement

• Dizziness should improve significantly with correction of anemia through intravenous iron therapy. 6
• If dizziness persists after hemoglobin normalization, pursue neurologic imaging and cardiovascular evaluation. 6

Menorrhagia Management

Gynecologic consultation is essential to address the underlying cause of menorrhagia and prevent recurrent iron deficiency. 1, 7

• Menstrual blood loss is the most common cause of iron deficiency anemia in premenopausal women. 1
• Treatment options include hormonal therapy (combined oral contraceptives, progestin IUD), tranexamic acid (use cautiously with anticoagulation), or procedural interventions. 6
• At age 50, consider endometrial sampling to exclude malignancy or hyperplasia as cause of abnormal bleeding. 6

Follow-Up Timeline

Short-term (2-4 weeks)

• Repeat CBC with platelets after initiating IV iron. 3, 2
• Reassess dizziness and functional status. 6
• Review LFT trends and hepatitis C status. 6

Medium-term (2-3 months)

• Confirm normalization of hemoglobin and platelet count. 3, 2
• Verify adequate iron stores (ferritin >100 ng/mL). 1, 7
• Reassess need for continued rosuvastatin based on LFT normalization. 6

Long-term (3-12 months)

• Monitor hemoglobin and iron indices every 3 months for the first year, then annually. 1, 7
• Ensure menorrhagia is adequately controlled to prevent recurrence. 1
• Continue apixaban indefinitely for secondary stroke prevention unless contraindications develop. 8

Critical Pitfalls to Avoid

• Do not discontinue apixaban without alternative anticoagulation, as this dramatically increases stroke risk post-CVA. 8
• Do not attribute thrombocytosis to a primary myeloproliferative disorder without first correcting iron deficiency. 3, 4
• Do not continue oral iron attempts when IV iron is clearly indicated for intolerance. 1
• Do not ignore elevated LFTs in a patient with hepatitis C history and concurrent statin use. 6
• Do not overlook the need for definitive menorrhagia treatment, as iron supplementation alone will not prevent recurrence. 1, 7