Can tissue plasminogen activator (tPA) be administered for cerebral vascular accident (CVA) if the patient is on Eliquis (apixaban)?

From the Guidelines

Administering tissue plasminogen activator (tPA) to a patient on Eliquis (apixaban) for a cerebrovascular accident (CVA) or stroke is generally not recommended due to the increased risk of bleeding complications. The American Heart Association/American Stroke Association guidelines, as outlined in the 2018 guidelines for the early management of patients with acute ischemic stroke 1, consider active use of anticoagulants like Eliquis a contraindication for tPA therapy. Key points to consider include:

• The safety and usefulness of factor Xa inhibitors, such as apixaban, in the treatment of acute ischemic stroke are not well established, with a Class IIb and Level of Evidence C-LD recommendation 1.
• Limited data exist on the use of factor Xa inhibitors in the acute treatment of patients with ischemic stroke, highlighting the need for caution and individualized decision-making 1.
• If the last dose of Eliquis was taken within the past 48 hours, tPA is usually contraindicated, emphasizing the importance of timing and anticoagulant effect assessment.
• Clinical decision-making should be individualized based on the time since the last dose, laboratory coagulation parameters, and the risk-benefit assessment, considering the potential for bleeding complications.
• In emergency situations, specialized coagulation tests like anti-Factor Xa levels may be used to assess the anticoagulant effect of Eliquis, guiding treatment decisions.
• For patients on Eliquis with acute ischemic stroke, alternative treatments such as mechanical thrombectomy might be considered if the patient is eligible, underscoring the need for a multidisciplinary approach in these complex cases. Always consult with a stroke specialist or neurologist for the most appropriate management.

From the Research

Administration of tPA for CVA in Patients on Eliquis

• The use of intravenous tissue-plasminogen activator (tPA) in patients with acute ischemic stroke who are taking non-vitamin K antagonist oral anticoagulants (NOACs), such as apixaban (Eliquis), is a topic of interest 2.
• A literature review of 55 studies with 492 NOAC patients receiving tPA found that the overall observed rates of symptomatic intracranial hemorrhage, mortality, and favorable outcomes were 4.3%, 11.3%, and 43.7%, respectively 2.
• Among patients taking apixaban, the rates of symptomatic intracranial hemorrhage, mortality, and favorable outcomes were not significantly different from those taking other NOACs 2.
• The study suggests that tPA may be reasonably well tolerated without prohibitive risks of bleeding complications in selected patients on NOACs, including apixaban 2.

Safety of Apixaban in Patients with Renal Impairment

• Apixaban has been shown to be effective and safe in preventing thromboembolic events in patients with atrial fibrillation and renal failure 3.
• A retrospective cohort analysis found that the incidence of bleeding in patients taking apixaban 5 mg or 2.5 mg twice daily was similar regardless of renal function 4.
• The study suggests that apixaban may be a safe option for patients with nonvalvular atrial fibrillation and severe renal impairment 4.

Considerations for tPA Administration in Patients on Apixaban

• The decision to administer tPA to a patient on apixaban should be made on a case-by-case basis, taking into account the patient's individual risk factors and the potential benefits and risks of treatment 2, 5.
• The use of reversal agents, such as idarucizumab for dabigatran, may be considered in patients taking NOACs who require tPA administration 2.