What are the recommendations for post-hospital care for a patient discharged after being treated for a condition related to blood thinners, such as warfarin (anticoagulant) or Direct Oral Anticoagulants (DOACs) like apixaban (Eliquis) or rivaroxaban (Xarelto), to minimize the risk of bleeding or thrombotic complications?

Post-Hospital Care for Patients on Anticoagulation

Immediate Post-Discharge Management

For most patients discharged after hospitalization while on warfarin or DOACs (apixaban, rivaroxaban), continue the anticoagulant at the same dose unless there was a bleeding complication during hospitalization. 1

Patients Discharged After Bleeding Events

Stop anticoagulation temporarily and assess both thrombotic risk and bleeding risk before restarting. 1

High Thrombotic Risk Criteria (Restart Within 7 Days):

• Atrial fibrillation with CHA₂DS₂-VASc score ≥2 2
• Mechanical heart valves, especially mitral position 2
• Recent stroke/TIA within 3 months 2
• Venous thromboembolism within 3 months 2
• History of unprovoked or recurrent VTE 2
• Left atrial or ventricular thrombus 2

Delay Restart if Any of These Apply:

• Bleeding occurred at a critical site (intracranial, intraspinal, intraocular, pericardial, intra-abdominal, retroperitoneal, intra-articular, or intramuscular) 1, 3
• High risk of rebleeding or death/disability with rebleeding 1
• Source of bleeding not yet identified 1
• Surgical or invasive procedures planned 1

For patients with major bleeding, restart apixaban at least 6 hours after bleeding is controlled and hemodynamic stability achieved. 2 For rivaroxaban, follow the same timing but ensure the patient takes it with food to optimize absorption. 4

Patients Discharged After COVID-19 Hospitalization

Do not routinely prescribe post-discharge thromboprophylaxis for COVID-19 patients without confirmed VTE or other anticoagulation indication. 1 This represents a significant change from earlier pandemic guidance, as the 2025 ASH guidelines now provide Level A evidence against routine prophylaxis based on the ACTIV-4c trial showing no benefit (apixaban 2.1% vs placebo 2.3% for death or thromboembolism). 1

Exception - High-Risk COVID-19 Patients Only:

Consider rivaroxaban 10 mg daily for approximately 30 days in highly selected patients with: 1

• Advanced age 1
• ICU stay during hospitalization 1
• Active cancer 1
• Prior history of VTE 1
• Known thrombophilia 1
• Severe immobility 1
• Elevated D-dimer >2 times upper limit of normal 1
• IMPROVE VTE score ≥4 1

The 2024 ISTH guidelines emphasize this should be reserved for the highest-risk subset only, as thromboembolism rates have decreased substantially since 2020 (from 1.55% VTE in early 2020 to 0.82% in 2021-2022). 1

Medication-Specific Instructions

Warfarin Post-Discharge:

• Continue INR monitoring every 1-2 weeks initially, then monthly once stable. 1
• Target INR 2.0-3.0 for most indications (atrial fibrillation, VTE). 1
• If major bleeding occurred, administer 5-10 mg IV vitamin K before discharge. 1

Apixaban (Eliquis) Post-Discharge:

• Atrial fibrillation: 5 mg twice daily with evening meal (2.5 mg twice daily if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL). 5
• VTE treatment: 10 mg twice daily for 7 days, then 5 mg twice daily. 1
• No routine laboratory monitoring required. 6
• Apixaban demonstrates lower major bleeding rates compared to rivaroxaban (RR 0.68,95% CI 0.61-0.76) and warfarin. 7, 8

Rivaroxaban (Xarelto) Post-Discharge:

• Atrial fibrillation: 20 mg once daily with evening meal (15 mg daily if CrCl 15-50 mL/min). 4
• VTE treatment: 15 mg twice daily with food for 21 days, then 20 mg once daily with food. 4
• Extended VTE prophylaxis: 10 mg once daily with or without food. 4
• Must be taken with food for 15 mg and 20 mg doses to ensure adequate absorption. 4
• Higher bleeding risk compared to apixaban (major bleeding RR 1.47, any bleeding RR 1.56). 8

Critical Safety Instructions for Patients

Bleeding Precautions:

Instruct patients to immediately contact their physician if they experience: 4

• Unusual bruising or bleeding 4
• Blood in urine or stool 4
• Prolonged bleeding from cuts 4
• Severe headache or dizziness 4
• Back pain, tingling, numbness, muscle weakness, or incontinence (signs of spinal hematoma) 4

Medication Adherence:

Emphasize that patients must not stop anticoagulation without physician consultation, as this dramatically increases stroke risk in atrial fibrillation patients. 4 For missed doses: 4

• Apixaban twice daily: Take as soon as remembered on the same day, then resume regular schedule
• Rivaroxaban once daily: Take as soon as remembered on the same day, then resume regular schedule
• Never double the dose to make up for a missed dose 4

Drug and Food Interactions:

Patients must inform all healthcare providers (including dentists) that they are taking anticoagulants before any procedure. 4 Avoid concomitant NSAIDs and antiplatelet agents unless specifically prescribed, as these significantly increase bleeding risk. 1

Follow-Up Scheduling

First Post-Discharge Visit (Within 7-14 Days):

• Assess for bleeding complications 1
• Verify medication adherence and correct dosing 5, 3
• Review fall risk and implement prevention strategies rather than discontinuing anticoagulation 2
• Check renal function for DOAC patients (apixaban, rivaroxaban require dose adjustment with renal impairment) 5

Ongoing Monitoring:

• Warfarin: INR checks every 1-2 weeks initially, then monthly 1
• DOACs: Clinical assessment every 3-6 months; renal function annually or more frequently if CrCl <60 mL/min 6
• All patients: Annual reassessment of indication for anticoagulation and bleeding/thrombotic risk 1

Special Populations

Patients with Frequent Falls:

Do not automatically discontinue anticoagulation in fall-prone patients. 2 Instead, prioritize thrombotic risk over fall risk and implement fall prevention measures: 2

• Review and minimize medications that increase fall risk 2
• Address polypharmacy 2
• Ensure appropriate anticoagulant dosing 2
• Involve physical therapy for gait and balance training 2

The American College of Cardiology emphasizes that even patients with high fall risk benefit from anticoagulation when thrombotic risk is high, as the risk of stroke far exceeds the risk of intracranial hemorrhage from falls. 2

Cancer Patients:

Prefer DOACs (apixaban, rivaroxaban) or LMWH over warfarin for VTE treatment in cancer patients. 1 Continue anticoagulation for at least 3-6 months, with consideration for indefinite therapy while cancer is active. 1