Management of Bleeding in Patients on Eliquis and Plavix

Prevention Strategies

• The American College of Cardiology recommends continuing both medications and using local hemostatic measures for minor bleeding from cuts, and discontinuing antiplatelet therapy should only be considered if bleeding cannot be controlled with local measures, weighing the risk-benefit against thrombotic complications 1, 2
• Avoid NSAIDs for pain management, as they significantly increase bleeding risk when combined with antiplatelet and anticoagulant therapy, according to the European Society of Gastrointestinal Endoscopy 3

Acute Management of Minor Bleeding

• Apply direct pressure for at least 10-15 minutes without interruption, and use topical hemostatic agents such as tranexamic acid-soaked gauze or topical thrombin, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6
• Consider nasal packing for epistaxis or appropriate wound closure techniques for cuts, following the guidelines of the American Academy of Otolaryngology-Head and Neck Surgery 6

Major Bleeding Management (Life-Threatening)

• For life-threatening bleeding on apixaban, administer andexanet alfa as the specific reversal agent, following the guidelines of the American College of Cardiology 1, 2, 4
• If andexanet alfa is unavailable, administer four-factor prothrombin complex concentrate (4F-PCC) or activated PCC, as recommended by the European Society of Cardiology 1, 2, 4, 7

Resumption After Temporary Discontinuation

• Resume apixaban at least 6 hours after hemostasis is achieved, assuming no ongoing bleeding or surgical contraindication, according to the European Society of Anaesthesiology 8, 3
• Resume clopidogrel once adequate hemostasis has been achieved, following the guidelines of the European Society of Gastrointestinal Endoscopy 3, 5

High-Risk Scenarios Requiring Cardiology Consultation

• Triple antithrombotic therapy (anticoagulant plus dual antiplatelet) requires communication with cardiology before making any medication changes, as recommended by the European Heart Journal 3, 7

Common Pitfalls to Avoid

• Do not routinely discontinue both medications for minor bleeding, as this dramatically increases thrombotic risk, according to the American College of Cardiology and the American Academy of Otolaryngology-Head and Neck Surgery 1, 6, 3
• Do not use reversal agents or blood products for minor bleeding that can be controlled with local measures, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6