Bleeding and overanticoagulation with apixaban
The following information applies to bleeding and overanticoagulation in patients taking apixaban therapeutically; for information on the management of apixaban poisoning, see Apixaban and rivaroxaban poisonings in the Toxicology and Toxinology guidelines.
For factors that increase risk of bleeding with apixaban, see Patient-associated factors that increase bleeding risk with anticoagulant therapy; clinical trials of apixaban excluded patients with these risk factors.
If bleeding occurs in patients taking apixaban therapeutically, stop apixaban and provide supportive treatment.
Apixaban is not dialysable as it is extensively bound to plasma protein. If it has been less than 2 hours since the last apixaban dose, consider giving oral activated charcoal to remove unabsorbed apixaban from the gastrointestinal tract. However, there will be some anticoagulant effect as apixaban is rapidly absorbed. Activated charcoal is an aspiration risk in nonintubated patients with an altered mental statusFrontera, 2016.
At the time of writing, andexanet alfa (a recombinant inactive factor Xa decoy molecule) is provisionally approved for reversal of anticoagulation in patients with life-threatening or uncontrolled bleeding due to apixaban1 – seek specialist haematologist advice. Although andexanet alfa may reverse the anticoagulant effect of apixaban, achieving haemostasis requires identification and treatment of the source of bleeding.
There is limited evidence on the use of prohaemostatic agents in direct-acting oral anticoagulant (DOAC)-related bleedingTran, 2014. For life-threatening bleeding or emergency surgery, consider the use of prohaemostatic agents, such as prothrombin complex concentrate, if available. Seek specialist haematologist advice; there is a risk of thrombotic complications. See Treatment for apixaban and rivaroxaban poisonings for example prothrombin complex concentrate dosages.
Once bleeding has been managed, whether and when to restart apixaban therapy should be determined in consultation with a specialist.
The combination of apixaban and dual antiplatelet therapy increases the risk of bleeding significantly. If bleeding occurs, consult the patient’s cardiologist before making any change to the antiplatelet therapy.