What is the best course of action for an elderly patient with afib on apixaban, bisoprolol, flomax, and advil PRN, with a history of NSTEMI and BPH, presenting with hematuria, joint pain, and lethargy?

Immediate Management of Hematuria in Elderly Patient on Apixaban

This patient requires immediate discontinuation of both apixaban and Advil (ibuprofen), urgent assessment of renal function and hemoglobin, and consideration of reversal agents if bleeding is severe. The combination of a DOAC with NSAIDs significantly increases bleeding risk, and hematuria in an elderly patient on anticoagulation represents a potentially serious bleeding complication that requires prompt intervention 1.

Critical First Steps

Immediate Medication Management

• Stop apixaban immediately - the European Society of Cardiology guidelines emphasize that DOACs increase bleeding risk substantially in elderly patients, particularly when combined with NSAIDs 1
• Discontinue Advil (ibuprofen) permanently - NSAIDs should be avoided in patients on anticoagulants due to dramatically increased bleeding risk, and this combination likely precipitated the hematuria 1
• Continue bisoprolol and flomax as these are not contributing to bleeding 1

Urgent Laboratory Assessment

• Check complete blood count to assess hemoglobin/hematocrit and determine severity of blood loss 2
• Assess renal function immediately (creatinine, BUN, calculate CrCl using Cockroft-Gault formula) - apixaban clearance is partially renal, and accumulation in renal dysfunction increases bleeding risk 1, 3, 4
• Check electrolytes including potassium, as elderly patients with renal dysfunction are at higher risk 1
• Urinalysis to confirm hematuria and rule out infection 2

Bleeding Severity Assessment and Reversal Considerations

If Major Bleeding is Present

• Consider andexanet alfa if bleeding is life-threatening - this reverses anti-FXa activity by 92% within minutes in apixaban-treated patients 1
• Alternative: 4-factor prothrombin complex concentrate (PCC) at 1500-2000 units if andexanet alfa unavailable - achieves effective hemostasis in 65-69% of patients with apixaban-related major bleeding 1
• The 2023 World Society of Emergency Surgery guidelines show andexanet alfa has lower 30-day mortality than PCC in propensity-matched analysis 1

If Bleeding is Moderate (Not Life-Threatening)

• Supportive care with close monitoring - apixaban has a half-life of approximately 12 hours, so anticoagulant effect will diminish over 24-48 hours after discontinuation 3
• Monitor hemoglobin every 6-12 hours until stable 2
• Ensure adequate hydration but avoid fluid overload given history of NSTEMI 1

Evaluation for Underlying Urologic Pathology

Urgent Imaging and Consultation

• CT urography or renal ultrasound should be performed once hemodynamically stable - hematuria in elderly patients frequently signals urologic malignancy, which cannot be missed 2
• Urology consultation is essential for elderly patients with hematuria, as this presentation has high association with bladder cancer or other serious pathology 2
• The BPH history and flomax use suggest possible prostatic source, but malignancy must be excluded 2

Addressing the Joint Pain and Lethargy

Rule Out Systemic Causes

• Consider uremia from acute kidney injury - the combination of joint pain, lethargy, and hematuria could indicate worsening renal function 1
• Check inflammatory markers (ESR, CRP) if systemic vasculitis is suspected, though less likely given presentation 2
• The "pale aching in all joints" may represent chronic NSAID use effects or could be unrelated musculoskeletal complaints 1

Restarting Anticoagulation Decision Algorithm

When to Resume Apixaban

Do NOT restart apixaban until:

1. Bleeding has completely resolved (no hematuria for 24-48 hours) 3
2. Urologic evaluation is complete and any structural lesions are addressed 2
3. Renal function is reassessed - if CrCl 25-30 mL/min, apixaban can still be used but requires careful monitoring 5, 4
4. All NSAIDs are permanently discontinued 1

Dose Adjustment Considerations

• Reduce to apixaban 2.5 mg twice daily if patient meets ≥2 of: age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL 3
• If CrCl 25-30 mL/min, standard dosing (5 mg twice daily or 2.5 mg twice daily based on criteria above) is appropriate per pharmacokinetic data 5, 4
• If CrCl <25 mL/min, apixaban use requires extreme caution and specialist consultation 3, 4

Critical Pitfalls to Avoid

Common Errors in This Scenario

• Assuming hematuria is "just from anticoagulation" without urologic workup - this misses malignancies 2
• Restarting apixaban too quickly before bleeding source is identified and controlled 3
• Allowing continued NSAID use - the combination with any anticoagulant is contraindicated in elderly patients 1
• Failing to reassess renal function - acute illness can worsen kidney function, increasing apixaban levels and bleeding risk 3, 4
• Not considering PPI prophylaxis when anticoagulation is restarted, given age and bleeding history 1

Monitoring After Discharge

• Renal function every 3-6 months given elderly status and bleeding history 3
• Clinical follow-up within 1 week to ensure bleeding resolution and review urologic findings 3
• Patient education on recognizing bleeding symptoms and absolute avoidance of NSAIDs, including over-the-counter products 3