In a patient with recurrent distal femoral deep vein thrombosis, chronic left popliteal DVT, hemoglobin dropping to 7.7 g/dL, negative occult stool, scheduled EGD and colonoscopy in two days, and currently on unfractionated heparin infusion after holding apixaban (Eliquis), what further management should be implemented?

Management of Recurrent DVT with Hemoglobin Drop on Apixaban

Immediate Management – Stop Heparin and Investigate the Bleeding Source

You should stop the heparin infusion immediately and hold all anticoagulation until the bleeding source is identified and controlled. 1 A hemoglobin drop from 10 to 7.7 g/dL represents a 2.3 g/dL decline that strongly suggests active bleeding, and continuing any anticoagulant—including unfractionated heparin—will worsen the hemorrhage and delay source control. 1

• Transfuse packed red blood cells to maintain hemoglobin ≥7 g/dL (or ≥8 g/dL if the patient has cardiovascular disease or is hemodynamically unstable). 1
• Repeat hemoglobin/hematocrit every 6–12 hours until the trend stabilizes, as ongoing occult bleeding may not be immediately apparent. 1
• Proceed with EGD and colonoscopy as scheduled in 2 days, but if the patient develops hemodynamic instability, melena, hematochezia, or hematemesis before then, perform urgent endoscopy within 24 hours. 1
• Check a type and screen, coagulation panel (PT/INR, aPTT), and platelet count to rule out coagulopathy or thrombocytopenia as contributing factors. 1

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Why Heparin Must Be Stopped Now

• Unfractionated heparin carries a 2–3% risk of major bleeding during the first 3 months of VTE treatment, and this patient has already demonstrated clinically significant hemorrhage. 1
• The risk of fatal or life-threatening bleeding (0.6% case-fatality rate) outweighs the short-term risk of thrombus extension when a 2.3 g/dL hemoglobin drop has occurred. 1
• Bridging anticoagulation with heparin is not required during the 24–48 hours before endoscopy in patients with DVT, as the acute thrombotic risk is low compared to the bleeding risk. 1, 2

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Resuming Anticoagulation After Endoscopy

If a Treatable Bleeding Source Is Found and Controlled

• Restart apixaban 10 mg orally twice daily for 7 days, then 5 mg twice daily as soon as adequate hemostasis is established (typically 24–48 hours post-procedure if no high-risk stigmata remain). 2
• Do not use heparin bridging when restarting apixaban; the drug achieves therapeutic levels within 3–4 hours and bridging increases bleeding risk without reducing thrombotic events. 1, 2
• If the bleeding lesion is high-risk (e.g., large ulcer with visible vessel, recent polypectomy site, esophageal varices), delay anticoagulation for 48–72 hours and consult gastroenterology for repeat endoscopy or intervention. 1

If No Bleeding Source Is Found

• Perform CT angiography of the abdomen and pelvis to exclude retroperitoneal hemorrhage, and consider capsule endoscopy or CT enterography to evaluate the small bowel. 1
• If imaging is negative and hemoglobin stabilizes, restart apixaban 10 mg twice daily for 7 days, then 5 mg twice daily, as the bleeding may have been self-limited or from an unidentified small-bowel source. 2
• If hemoglobin continues to drop despite negative workup, place a temporary inferior vena cava (IVC) filter and hold anticoagulation until the bleeding resolves. 1

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IVC Filter Placement – Only If Anticoagulation Cannot Be Resumed

• Place a retrievable IVC filter only if the bleeding source cannot be controlled and anticoagulation must be withheld for >2 weeks. 1
• Routine IVC filter placement in addition to anticoagulation is strongly discouraged, as filters do not reduce mortality and increase long-term DVT recurrence risk. 1
• Remove the filter as soon as anticoagulation can be safely restarted (typically within 4–6 weeks), as prolonged filter dwell time increases thrombotic complications. 1

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Why Apixaban Should Be Restarted (Not Switched to Another Agent)

• Apixaban has the lowest gastrointestinal bleeding risk among all direct oral anticoagulants, making it the preferred choice if GI pathology is identified. 1
• Switching to rivaroxaban, edoxaban, or dabigatran will not reduce bleeding risk and may increase it, as these agents have higher GI bleeding rates than apixaban. 1
• Switching to warfarin requires 5 days of heparin bridging, which will further increase bleeding risk during the transition period. 1, 2
• Low-molecular-weight heparin (LMWH) is not superior to apixaban for bleeding risk and requires daily injections, reducing adherence. 1

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Duration of Anticoagulation After Bleeding Is Controlled

• Continue apixaban for a minimum of 3 months from the date of the recurrent DVT, as this is the second unprovoked event and mandates at least 3 months of treatment. 1
• After 3 months, transition to indefinite extended-phase anticoagulation with apixaban 2.5 mg twice daily, as a second unprovoked DVT carries a >10% annual recurrence risk and requires lifelong therapy. 1, 3
• Reassess the risk-benefit balance annually, but do not stop anticoagulation unless the bleeding risk becomes prohibitive (e.g., recurrent life-threatening hemorrhage despite source control). 1

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Critical Pitfalls to Avoid

• Do not continue heparin "just to cover the DVT" while waiting for endoscopy; this will worsen the bleeding and may cause hemodynamic instability. 1
• Do not place an IVC filter preemptively before endoscopy; filters are indicated only when anticoagulation is absolutely contraindicated for a prolonged period. 1
• Do not switch to warfarin after the bleeding is controlled; apixaban has superior safety and does not require heparin bridging. 1, 2
• Do not restart anticoagulation at a reduced dose (e.g., apixaban 2.5 mg twice daily) during the initial 3-month treatment phase; the full treatment dose (10 mg BID × 7 days, then 5 mg BID) is required to prevent thrombus extension. 2
• Do not stop anticoagulation after 3 months; this is the second unprovoked DVT and requires lifelong therapy. 1