Management of Eliquis After a Fall with Bruising
Do not hold Eliquis (apixaban) for a simple fall with bruising alone—this is an expected minor bleeding event that does not warrant discontinuation of anticoagulation in patients with atrial fibrillation. 1, 2
Key Clinical Principle
Falls and bruising are not contraindications to continuing anticoagulation. The European Society of Cardiology guidelines explicitly state that falls and dementia are associated with increased mortality in AF patients, but without evidence that these conditions markedly increase the risk of intracranial hemorrhage. 1 Anticoagulation should only be withheld from patients with severe uncontrolled falls (e.g., epilepsy or advanced multisystem atrophy with backwards falls). 1
Assessment of Bleeding Severity
Determine if this represents minor versus major bleeding:
Minor bleeding (bruising alone): Continue apixaban without interruption. The FDA label explicitly warns that "you may bruise more easily" while taking apixaban, and this is an expected effect. 2
Major bleeding indicators requiring intervention: Unexpected pain/swelling, hemodynamic instability, large expanding hematomas, signs of intracranial bleeding (headaches, dizziness, weakness), or bleeding that cannot be controlled. 2
When to Actually Hold Apixaban
Hold apixaban only if:
- Active severe bleeding with hemodynamic compromise is present 1
- Intracranial hemorrhage is confirmed 1
- Major bleeding requiring transfusion or reversal agents occurs 1
For minor bleeding like bruising, the stroke risk from discontinuing anticoagulation far outweighs the bleeding risk. 1
Risk Mitigation Strategies
Instead of holding apixaban, optimize modifiable bleeding risk factors:
- Control blood pressure aggressively (target <160 mmHg systolic) 1
- Review and discontinue NSAIDs, aspirin, or other antiplatelet agents if not absolutely necessary 1, 2
- Assess for alcohol abuse and counsel on reduction 1
- Verify correct apixaban dosing (inappropriate underdosing increases thrombotic risk, but overdosing increases bleeding) 1, 3
Critical Pitfall to Avoid
The most dangerous mistake is stopping anticoagulation unnecessarily. The FDA label warns: "If you stop taking apixaban, you may have increased risk of forming a clot in your blood. Do not stop taking apixaban tablets without talking to the doctor who prescribes it for you. Stopping apixaban increases your risk of having a stroke." 2
When to Reassess
Seek immediate evaluation if:
- Bruising progresses to large expanding hematomas
- New neurological symptoms develop (headache, confusion, focal weakness)
- Signs of compartment syndrome appear (severe pain, numbness, muscle weakness)
- Hemodynamic instability occurs 2
For isolated bruising from a mechanical fall, reassure the patient this is expected, continue apixaban, and focus on fall prevention strategies rather than anticoagulation discontinuation. 1, 2