Can a patient with a recent scattered subarachnoid hemorrhage, who was previously on Eliquis (apixaban) for a recent pulmonary embolism, be restarted on Eliquis (apixaban)?

From the Guidelines

Restarting Eliquis (apixaban) after a subarachnoid hemorrhage in a patient with recent pulmonary embolism should be done with caution, considering the high risk of rebleeding, and ideally after a period of at least 4-8 weeks, as suggested by the management principles outlined in the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1. When assessing the severity of the bleed, it's crucial to determine if the bleeding is at a critical site or life-threatening, which would classify it as a major bleed according to the criteria provided in the study 1. Given that the patient has a scattered subarachnoid hemorrhage, this would be considered bleeding at a critical site. The management approach should follow the guidelines for major bleeds, which include stopping the oral anticoagulant (OAC) and antiplatelet agent(s) if applicable, providing local therapy/manual compression, administering vitamin K if the patient is on a vitamin K antagonist (VKA), and offering supportive care and volume resuscitation 1. For patients on direct-acting oral anticoagulants (DOACs) like apixaban, the decision to restart anticoagulation should be based on the individual's risk of thrombosis versus the risk of recurrent bleeding, and should ideally be made in consultation with relevant specialists 1. Key considerations include the timing of restarting anticoagulation, which should be guided by the resolution of the hemorrhage, stability of the patient's neurological status, and control of other risk factors for bleeding, as well as the potential use of temporary measures such as an inferior vena cava filter for protection against recurrent pulmonary embolism. The dose of Eliquis upon restarting may need to be adjusted, potentially starting with a lower dose, to balance the risks and benefits, although specific dosing recommendations are not provided in the referenced guideline 1. Ultimately, the decision to restart Eliquis must be tailored to the individual patient's clinical scenario, weighing the risks of anticoagulant therapy against the benefits of preventing further thrombotic events.

From the FDA Drug Label

If anticoagulation with apixaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant Epidural or spinal hematomas may occur in patients treated with apixaban who are receiving neuraxial anesthesia or undergoing spinal puncture. Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding

The patient had a recent subarachnoid hemorrhage and was on apixaban (Eliquis) for pulmonary embolism. Given the patient's recent hemorrhage, it is not recommended to restart apixaban without careful consideration of the risks and benefits. The FDA drug label warns about the risk of spinal/epidural hematoma with anticoagulation, particularly in patients with a history of traumatic or repeated epidural or spinal punctures.

• The patient should be closely monitored for signs and symptoms of neurological impairment.
• Consider alternative anticoagulation options or bridging therapy during the period of increased risk of bleeding.
• The decision to restart apixaban should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2.

From the Research

Subarachnoid Hemorrhage and Anticoagulation Therapy

• Subarachnoid hemorrhage (SAH) is a neurologic emergency due to bleeding into the subarachnoid space, with mortality reaching 50% 3.
• The clinical presentation of SAH is most often in the form of headache, classically defined as maximal at onset and worst of life 3.
• Noncontrast brain computed tomography (CT) performed within 6 hours of symptom onset has sensitivity approaching 100% for diagnosing SAH 3.

Venous Thromboembolism in Subarachnoid Hemorrhage

• Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality among patients recovering from aneurysmal subarachnoid hemorrhage (aSAH) 4.
• Prophylactic heparin reduces the risk of VTE, but the optimal timing for its initiation among aSAH patients remains unclear 4.
• Delayed heparin introduction was significantly associated with an increased risk of symptomatic VTE (sVTE) in patients with aSAH 4.

Anticoagulation Therapy in Aneurysmal Subarachnoid Hemorrhage

• Anticoagulation therapy has not been identified as a significant and independent factor influencing functional outcome in patients suffering from SAH 5.
• However, cautious management is necessary in patients with known anticoagulation therapy before SAH 5.
• The use of low-dose intravenous heparin therapy in aneurysmal subarachnoid hemorrhage is being investigated in a randomized controlled clinical trial 6.

Management of Subarachnoid Hemorrhage

• Management of patients with SAH follows standard resuscitation of critically ill patients with the emphasis on reducing risks of rebleeding and avoiding secondary brain injuries 7.
• The gold standard for diagnostic evaluation of SAH remains noncontrast head computed tomography (CT) followed by lumbar puncture if the CT is negative for SAH 7.