Can Eliquis (Apixaban) Worsen Iron Deficiency in CKD Stage 2?
Yes, Eliquis (apixaban) 5mg twice daily can worsen iron deficiency, particularly through gastrointestinal blood loss, which is the most common bleeding complication of anticoagulants and a well-recognized cause of iron deficiency in patients on anticoagulation therapy. 1
Mechanism of Iron Loss with Anticoagulation
- Anticoagulants, including apixaban, contribute to iron deficiency primarily through occult or overt gastrointestinal bleeding, which depletes iron stores over time 1
- In patients with chronic heart failure (a common indication for anticoagulation), anticoagulants and antiplatelet agents are specifically identified as contributors to GI blood loss that can lead to iron deficiency 1
- The bleeding risk with apixaban is dose-dependent and influenced by renal function, though your CKD stage 2 (GFR 60-89 mL/min) represents relatively preserved kidney function 1, 2
Your Specific Risk Profile with CKD Stage 2
- With CKD stage 2, you are at the standard 5mg twice daily dose of apixaban, which is appropriate for your level of kidney function 1
- Your bleeding risk is lower than patients with more advanced CKD, as stage 3 CKD (GFR 30-60) is an independent predictor of major hemorrhage with a hazard ratio of 2.2 3
- However, any degree of CKD increases the complexity of managing iron deficiency, as renal failure itself contributes to iron deficiency through reduced iron intake, reduced absorption, and blood loss 1
Clinical Implications for Iron Management
If you have confirmed iron deficiency (transferrin saturation ≤20% and ferritin ≤100 μg/L for CKD stage 2), you should undergo endoscopic evaluation of the upper and lower GI tract to exclude treatable causes of bleeding, particularly given your anticoagulation 1
Iron Replacement Strategy:
- Start with oral iron supplementation at 200mg elemental iron daily in divided doses (e.g., ferrous sulfate 325mg tablets, 65mg elemental iron each, taken 2-3 times daily) 4, 5
- Take oral iron on an empty stomach without food or other medications for maximum absorption, avoiding food within 2 hours before or 1 hour after dosing 4, 5
- Monitor your response after 1-3 months by checking hemoglobin, ferritin, and transferrin saturation 5
- If oral iron fails to correct your iron deficiency after this trial period, switch to intravenous iron, as oral iron may be inadequate in CKD patients even at stage 2 1, 5
Monitoring Recommendations
- Check iron parameters (transferrin saturation and ferritin) every 3 months once on stable iron replacement 5
- Monitor for signs of bleeding throughout your anticoagulation therapy, including checking stool for occult blood and watching for symptoms like fatigue worsening, dark stools, or unexplained anemia 6
- Have your kidney function reassessed at least annually, as declining renal function increases both bleeding risk and iron deficiency risk 1
Critical Safety Consideration
The decision about endoscopic evaluation should ideally be made in conjunction with your cardiologist or the physician managing your anticoagulation, as the risks and benefits of temporarily holding apixaban for procedures must be weighed against your stroke risk 1