How to manage a patient on Eliquis (apixaban) with continued bleeding after skin lesion removal by dermatology?

Management of Continued Bleeding After Dermatologic Procedure in a Patient on Eliquis

Stop Eliquis immediately and apply local hemostatic measures including manual compression, topical hemostatic agents, and consider suturing or cautery of the bleeding site. 1

Initial Assessment and Classification

Determine if this is a major or non-major bleed based on the following criteria 1:

Major bleed criteria (if ≥1 applies):

• Bleeding at a critical site (intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular with compartment syndrome, retroperitoneal) 1
• Hemodynamic instability 1
• Hemoglobin decrease ≥2 g/dL or transfusion of ≥2 units RBCs 1

For post-dermatologic bleeding: This is almost certainly a non-major bleed unless the patient has developed hemodynamic instability or significant hemoglobin drop, which would be extremely unusual for skin lesion removal 1.

Immediate Management Steps

For Non-Major Bleeding (Most Likely Scenario)

1. Stop Eliquis - Hold the next dose(s) until bleeding is controlled 1

2. Apply aggressive local measures 1:

   • Direct manual compression for 10-15 minutes minimum (do not peek early) 1
   • Apply topical hemostatic agents (thrombin, gelatin sponges, oxidized cellulose) 1
   • Consider aluminum chloride or silver nitrate for superficial oozing 1
   • Suture or cauterize the bleeding site if local measures fail 1

3. Do NOT administer reversal agents - For non-major bleeding on apixaban, reversal agents (andexanet alfa, PCCs) are not indicated and should not be used 1

4. Provide supportive care 1:

   • Volume resuscitation if needed
   • Assess for contributing factors (thrombocytopenia, uremia, liver disease, concomitant antiplatelet use) 1

5. Verify appropriate Eliquis dosing - Confirm the patient is on the correct dose for their indication, renal function, age, and weight 1

If Major Bleeding Develops (Rare)

If the patient develops hemodynamic instability or meets major bleeding criteria 1:

1. Stop Eliquis and any antiplatelet agents 1
2. Apply local hemostatic measures as above 1
3. Consider andexanet alfa (specific reversal agent for apixaban) if life-threatening 1, 2
4. Alternative: 4-factor prothrombin complex concentrate (PCC) if andexanet unavailable, though not formally studied for apixaban 1, 2
5. Provide aggressive supportive care and volume resuscitation 1

Key Points About Eliquis and Dermatologic Procedures

• Dermatologic procedures including skin cancer excision are considered low bleeding risk 1
• Studies show that continuing anticoagulation during minor dermatologic procedures results in only a 3-fold increase in minor, self-limiting bleeding with <5% major bleeding risk 1
• Most post-procedure bleeding is self-limiting and responds to local measures 1

When to Restart Eliquis

Delay restarting anticoagulation if 1:

• High risk of rebleeding exists 1
• Source of bleeding not yet identified 1
• Further surgical procedures planned 1

Restart Eliquis when 1:

• Bleeding is controlled with local measures 1
• Adequate hemostasis achieved (typically 24-48 hours for dermatologic sites) 1
• Patient has ongoing indication for anticoagulation 1

The pharmacodynamic effect of apixaban persists for at least 24 hours after the last dose (approximately two half-lives), so waiting 24-48 hours after bleeding control before restarting is prudent 2.

Common Pitfalls to Avoid

• Premature use of reversal agents - These are not indicated for non-major bleeding and expose patients to unnecessary thrombotic risk 1
• Inadequate local compression time - Apply firm, continuous pressure for full 10-15 minutes without checking 1
• Overlooking concomitant antiplatelet therapy - Aspirin, NSAIDs, or other antiplatelet agents significantly increase bleeding risk and should be identified and stopped if present 1, 2
• Restarting anticoagulation too early - Ensure adequate hemostasis before resuming Eliquis to prevent rebleeding 1
• Not assessing for appropriate dosing - Verify the patient is on correct dose for renal function, as overdosing increases bleeding risk 1