What is the management approach for a 43-year-old patient with paraplegia, deep vein thrombosis (DVT) and pulmonary embolism (PE) on Eliquis (apixaban), with an ostomy bag, end-stage renal disease (ESRD) on dialysis, presenting with recurrent asymptomatic tachycardia and severe anemia?

From the Guidelines

This 43-year-old patient with multiple complex conditions (paraplegia, DVT/PE on Eliquis, ostomy, ESRD on dialysis) presenting with recurrent asymptomatic tachycardia and significant anemia (Hgb 7) requires immediate attention to prevent further morbidity and mortality.

Key Considerations

• The patient's anemia is likely contributing to the tachycardia as a compensatory mechanism to maintain oxygen delivery, and thus, addressing the anemia is crucial.
• The patient is already on anticoagulation with Eliquis for DVT/PE, and according to the 2019 ESC guidelines for pulmonary embolism 1, anticoagulation should be continued unless there are contraindications.
• Given the patient's ESRD, the dose of Eliquis should be adjusted accordingly, and the patient should be monitored for signs of bleeding, particularly gastrointestinal bleeding given the presence of an ostomy.

Recommendations

• Transfuse 1-2 units of packed red blood cells to address the anemia, as this will help reduce the strain on the heart and potentially alleviate the tachycardia.
• Continue Eliquis at the renally-adjusted dose for ESRD (2.5mg twice daily), as recommended by the guidelines 1.
• Perform a thorough evaluation for bleeding sources, particularly gastrointestinal bleeding given the ostomy.
• Monitor fluid status carefully during dialysis sessions, as volume shifts can exacerbate tachycardia.
• Check electrolytes (particularly potassium, calcium, and magnesium) as abnormalities are common in ESRD and can trigger arrhythmias.
• Consider a cardiology consultation for Holter monitoring to characterize the tachycardia pattern, as recommended by the 2024 ESC guidelines for atrial fibrillation 1.

Rationale

The patient's complex medical conditions, including paraplegia, DVT/PE, ostomy, and ESRD, increase the risk of morbidity and mortality. Addressing the anemia and continuing anticoagulation are crucial to preventing further complications. The guidelines recommend a thorough evaluation and management of comorbidities and risk factors, as well as careful monitoring of the patient's condition to prevent adverse outcomes 1.

From the FDA Drug Label

The recommended dose of apixaban tablets for most patients is 5 mg taken orally twice daily. The recommended dose of apixaban tablets is 2.5 mg twice daily in patients with at least two of the following characteristics: • age greater than or equal to 80 years • body weight less than or equal to 60 kg • serum creatinine greater than or equal to 1.5 mg/dL Reduction in the Risk of Recurrence of DVT and PE The recommended dose of apixaban tablets is 2.5 mg taken orally twice daily after at least 6 months of treatment for DVT or PE [see Clinical Studies (14.3)].

The patient has ESRD and is on dialysis, which may affect the serum creatinine level.

• Dose adjustment may be necessary due to the patient's serum creatinine level, which is likely to be elevated in ESRD.
• The patient's current dose of Eliquis (apixaban) should be evaluated based on their renal function and other clinical factors. However, the provided information is not sufficient to determine the exact dose, and the decision should be made based on the patient's individual characteristics and clinical judgment 2.

From the Research

Patient Profile

• 43-year-old patient with paraplegia, DVT, and PE on Eliquis
• Has an ostomy bag and ESRD in dialysis
• Presenting with recurrent asymptomatic tachycardia and Hgb of 7

Relevant Studies

• A study published in 2018 3 reported a case of supraventricular tachycardia associated with severe anemia, highlighting the importance of considering anemia as a potential cause of tachycardia
• Another study from 2018 4 discussed the pathophysiology of anemia in critical illness and the limitations of using hemoglobin concentration as a surrogate for oxygen delivery
• A 2021 review article 5 discussed the mechanisms involved in anemia associated with chronic kidney disease, including decreased endogenous erythropoietin production and iron deficiency
• A literature review from 2021 6 summarized the role of erythropoiesis stimulating agents in the treatment of anemia, highlighting their benefits and risks
• A 2016 study 7 found that iron supplementation improved hematopoietic response and reduced the need for red blood cell transfusions in patients with chemotherapy-induced anemia

Potential Considerations

• The patient's low hemoglobin level (Hgb of 7) may be contributing to their tachycardia, and treatment of the anemia may be necessary to address the tachycardia
• The patient's ESRD and dialysis may be contributing to their anemia, and treatment with erythropoiesis stimulating agents or iron supplementation may be necessary
• The patient's use of Eliquis may increase their risk of bleeding, and careful consideration should be given to the use of iron supplementation or other treatments that may increase this risk