From the Guidelines
Eliquis can typically be restarted 24-48 hours after resolution of a hemothorax, once hemostasis is confirmed and the risk of rebleeding is low, as per the latest guidelines from the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines 1. The decision to resume anticoagulation should be individualized based on the patient's thrombotic risk versus bleeding risk.
- For patients with high bleeding risk, Eliquis should be withheld for a longer period, typically 5-7 days after resolution of the hemothorax.
- For patients with low to moderate bleeding risk, Eliquis can be restarted 24-48 hours after resolution of the hemothorax.
- The standard Eliquis dosing of 5 mg twice daily (or 2.5 mg twice daily for patients meeting dose reduction criteria) can be resumed. Before restarting, a follow-up chest X-ray or CT scan should confirm complete resolution of the hemothorax with no residual fluid collection.
- In patients with high thrombotic risk who cannot tolerate delays in anticoagulation, bridging with prophylactic-dose low molecular weight heparin may be considered 2-3 days after hemothorax resolution, followed by transition to Eliquis. Close monitoring for recurrent bleeding is essential during the first few weeks after resuming anticoagulation. The timing of anticoagulation resumption balances preventing thrombotic events while allowing adequate healing of the pleural space to minimize rebleeding risk, as supported by the findings of the PAUSE study and the EMIT-AF/VTE study 1.
From the Research
Eliquis after Resolution of Hemothorax
- The use of anticoagulants like Eliquis (apixaban) after the resolution of hemothorax is a complex decision that depends on various factors, including the patient's underlying condition, the risk of recurrent thrombosis, and the risk of bleeding 2, 3.
- There is limited evidence on the specific use of Eliquis after hemothorax, but studies suggest that direct oral anticoagulants (DOACs) like apixaban can be effective in preventing recurrent venous thromboembolism (VTE) 3.
- However, the risk of bleeding, including spontaneous hemothorax, is a concern with anticoagulant therapy, and healthcare providers should have a high index of suspicion for this complication in patients receiving DOACs 2, 4.
- The management of hemothorax, including the use of drainage and anticoagulation, is crucial in preventing recurrent bleeding and promoting resolution of the condition 5.
- A practical approach to resuming anticoagulation after hemorrhage, including hemothorax, involves individualizing the decision based on the patient's risk factors and the severity of the bleeding event 6.
- The choice of anticoagulant and the timing of resumption should be guided by the patient's specific needs and the availability of evidence-based guidelines 3, 6.