Should Eliquis (apixaban) be held in a patient presenting with gastrointestinal bleeding?

Should Eliquis Be Held for Tarry Stool?

Yes, Eliquis (apixaban) must be discontinued immediately upon presentation with tarry stool, which indicates gastrointestinal bleeding. 1

Immediate Management

Withhold apixaban at presentation with any evidence of GI bleeding, including melena (tarry stool). 1 The British Society of Gastroenterology provides a strong recommendation to interrupt direct oral anticoagulant therapy immediately when patients present with gastrointestinal hemorrhage. 1

• The anticoagulant effect of apixaban dissipates relatively quickly due to its short half-life (approximately 12 hours), so in most cases simply withholding the medication and providing supportive care is sufficient. 1
• Do not restart apixaban until adequate hemostasis has been established. 2

Severity-Based Approach

For Stable, Low-Risk Bleeding

• Discontinue apixaban and monitor closely 1
• Provide supportive care and resuscitation as needed 1
• The drug's anticoagulant effects will dissipate within 24-48 hours in patients with normal renal function 1

For Severe or Life-Threatening Hemorrhage

• Consider reversal with andexanet alfa (FDA-approved specific reversal agent for apixaban) for life-threatening or uncontrolled bleeding 1, 3
• Idarucizumab is NOT effective for apixaban (it only reverses dabigatran) 1
• Prothrombin complex concentrate may have some benefit but is less effective than specific reversal agents 1
• Seek urgent hematology consultation for severe bleeding on DOACs 1

Timing of Reinitiation

Restart apixaban at a maximum of 7 days after bleeding has stopped in patients with low thrombotic risk. 1 This timing balances the risk of rebleeding against thromboembolic complications.

High Thrombotic Risk Patients

For patients with high thrombotic risk (prosthetic metal heart valve in mitral position, atrial fibrillation with prosthetic valve or mitral stenosis, or venous thromboembolism within 3 months):

• Consider bridging with low molecular weight heparin at 48 hours after hemostasis is achieved 1
• This approach has not been formally tested in acute GI bleeding but may be beneficial in very high-risk patients 1

Critical Considerations

Apixaban carries increased risk of gastrointestinal bleeding compared to warfarin. A 2015 meta-analysis found that while apixaban had a null effect on GI bleeding compared to warfarin (unlike rivaroxaban and high-dose dabigatran which significantly increased GI bleeding), recent data from the ARTESiA trial showed apixaban increased major GI bleeding compared to aspirin (HR 2.23). 4, 5

Risk Factors for Major Bleeding

The following factors significantly increase bleeding risk and should prompt extra caution:

• NSAID use (HR 10.25 - the strongest predictor) 5
• Active malignancy (HR 2.87) 5
• Advanced age (HR 1.47 per 5-year increase) 5
• Renal impairment (prolongs apixaban half-life) 1

Common Pitfalls to Avoid

• Do not use vitamin K, fresh frozen plasma, or protamine sulfate - these are ineffective for reversing apixaban 1
• Do not delay reversal in life-threatening bleeding while waiting for laboratory confirmation - clinical judgment should guide the decision to use andexanet alfa 1, 3
• Do not restart apixaban too early (before 7 days) as this doubles the risk of rebleeding without significantly reducing thromboembolism 1
• Do not forget to address the underlying cause of bleeding before restarting anticoagulation 1