What is the management of a geriatric patient who has experienced a fall while taking Eliquis (apixaban)?

From the Guidelines

Management of a geriatric patient who has fallen while on Eliquis (apixaban) requires prompt evaluation and careful decision-making, with a focus on assessing for bleeding complications and balancing the risk of thromboembolism against bleeding risk, as recommended by the most recent guidelines 1, 2. The patient's evaluation should start with a thorough physical examination focusing on neurological status, vital signs, and evidence of external trauma. Obtain a CT scan of the head if there are any neurological symptoms, loss of consciousness, or significant head trauma. Laboratory tests should include CBC, coagulation studies, and renal function. If active bleeding is present, consider temporarily holding Eliquis and consulting hematology regarding potential reversal with andexanet alfa in severe cases. For patients without significant bleeding, Eliquis can typically be continued after 24-48 hours of observation, as the risk of thromboembolism from discontinuation often outweighs bleeding risk, as seen in studies 1, 2. Some key points to consider in the management of geriatric trauma patients include:

• Avoiding under-triage and providing early, targeted, and aggressive care
• Early admission to an Intensive Care Unit (ICU) for high-risk patients
• Assessing and managing "frail" patients
• Using systolic blood pressure (SBP) and shock index (SI) as indicators of hemodynamic instability
• Considering the patient's comorbidities, polypharmacy, and medication use when making management decisions
• Implementing fall prevention strategies, including physical therapy referral, assistive devices, medication adjustments, and home safety modifications, as recommended by the USPSTF 3, 4. The decision to continue or modify anticoagulation should balance the patient's thromboembolic risk (particularly for those with atrial fibrillation) against their bleeding risk, with shared decision-making involving the patient and family, taking into account the latest evidence and guidelines 1, 2.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Geriatric Fall with Eliquis Management

• Geriatric falls are a significant concern, especially in patients taking anticoagulants like Eliquis (apixaban) 5
• The use of anticoagulants in older persons at risk for falls is a therapeutic dilemma, requiring careful consideration of the benefits and risks 6

Physical Exam and Assessment

• A comprehensive physical exam and assessment are crucial in evaluating the risk of falls in geriatric patients taking Eliquis 6
• The assessment should include a review of the patient's medical history, medication list, and physical function, as well as a evaluation of their fall risk 7

Management of Eliquis in Geriatric Patients

• The management of Eliquis in geriatric patients requires careful consideration of the patient's individual risk factors, including their risk of falls and bleeding 6
• The use of Eliquis may be appropriate in geriatric patients with a high risk of stroke or venous thromboembolism, but the decision to use this medication should be made on a case-by-case basis 5
• Medication review and falls prevention strategies should be implemented before prescribing anticoagulation, and deprescribing should be considered in patients with severe frailty, limited life expectancy, or increased bleeding risk 6

Risks Associated with Anticoagulation

• The use of anticoagulants, including Eliquis, is associated with an increased risk of bleeding, particularly in geriatric patients 6, 8, 9
• The risk of bleeding should be carefully weighed against the benefits of anticoagulation in each individual patient 6
• The use of anticoagulants may also be associated with an increased risk of falls, particularly in patients taking certain medications, such as psychotropic drugs and benzodiazepines 7

Prevention of Falls

• Prevention of falls is critical in geriatric patients taking Eliquis, and may involve strategies such as medication review, physical therapy, and environmental modifications 7
• Computer-assisted alerts coupled with electronic prescribing tools may be a promising approach to lowering the risk of falls in geriatric patients taking Eliquis 7