Is it okay to administer Eliquis (apixaban) 5mg to a patient with a history of gastrointestinal (GI) bleed, pulmonary embolism (PE) with right heart strain, and code white, who has a hemoglobin (HGB) level of 7.1, indicating severe anemia, and no active bleeding noted?

From the Guidelines

I would not recommend giving Eliquis 5mg tonight due to the patient's significant drop in hemoglobin from 7.9 to 7.1 without a clear explanation. While there is no active bleeding noted currently, the recent hemoglobin decline suggests possible occult bleeding, particularly concerning given the patient's admission for GI bleed. According to the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1, a hemoglobin decrease ≥2 g/dL is considered a major bleed, and in this case, the decrease is 0.8 g/dL, which although not meeting the exact criteria, still raises concern for potential ongoing bleeding. Anticoagulation with Eliquis in this setting could potentially worsen bleeding and further decrease hemoglobin levels. I would recommend holding the Eliquis dose tonight, consulting with the primary team about the hemoglobin drop, considering additional workup to identify potential ongoing bleeding sources, and reassessing anticoagulation once hemoglobin stabilizes. The risk of worsening a potential bleed likely outweighs the immediate thrombotic risk from temporarily holding anticoagulation, especially in a monitored hospital setting. Once the cause of the hemoglobin drop is identified and addressed, anticoagulation can be safely resumed based on the patient's PE/DVT history.

Some key points to consider in this decision include:

• The patient's history of GI bleed and current hemoglobin level of 7.1
• The potential for occult bleeding given the recent hemoglobin decline
• The need to balance the risk of thrombosis with the risk of bleeding in this patient
• The importance of monitoring and reassessing anticoagulation in a hospital setting
• The guidance from the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1 and the NCCN clinical practice guidelines in oncology 1, although the latter is more focused on cancer-associated venous thromboembolic disease, it still provides valuable insights into anticoagulation management.

Given the most recent and highest quality study available, holding the Eliquis dose tonight is the most appropriate course of action to prioritize the patient's safety and minimize the risk of worsening a potential bleed.

From the FDA Drug Label

Apixaban tablets are contraindicated in patients with the following conditions: • Active pathological bleeding

5.2 Bleeding Apixaban tablets increases the risk of bleeding and can cause serious, potentially fatal, bleeding

The patient has a history of GI bleed and currently has a low hemoglobin level of 7.1. Although there is no active bleeding noted, caution is advised. The FDA drug label recommends discontinuing apixaban in patients with active pathological hemorrhage, but it does not provide clear guidance on administration in patients with a history of bleeding and low hemoglobin levels. It is not recommended to give the medication due to the increased risk of bleeding. 2

From the Research

Patient's Current Condition

The patient is a downgrade from ICU with a history of GI bleed, PE with right heart strain, and code white. The patient has a history of UTI, HLD, MI, PE/DVT and is currently on eliquis 5mg due tonight, but her HGB is 7.1, which is lower than the previous value of 7.9.

Considerations for Administering Eliquis

• No active bleeding is noted in the patient.
• The patient's low hemoglobin level (HGB 7.1) may be a concern when considering anticoagulant therapy.

Relevant Studies

• A study published in 2018 3 found that the incidence of hospitalization for upper gastrointestinal tract bleeding was lower for patients prescribed apixaban compared to those prescribed rivaroxaban or warfarin.
• Another study published in 2017 4 found that the incidence of gastrointestinal bleeding was lower in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) compared to those taking warfarin.
• A study published in 2020 5 found that prior gastrointestinal bleeding was associated with an increased risk of subsequent major gastrointestinal bleeding in patients with atrial fibrillation treated with apixaban or warfarin.
• A study published in 2024 6 found that risk factors for bleeding in cancer patients treated with apixaban included age above 74 years, low body mass index, and low hemoglobin levels.
• A study published in 2018 7 found that apixaban binds to hemoglobin, which can affect its plasma levels and pharmacokinetics.

Key Points to Consider

• The patient's low hemoglobin level may increase the risk of bleeding when taking apixaban.
• The patient's history of GI bleed and current condition should be carefully considered when deciding whether to administer eliquis.
• The studies suggest that apixaban may be a safer option compared to other anticoagulants in terms of gastrointestinal bleeding risk, but the patient's individual risk factors should be taken into account.