A 78-year-old client on chronic apixaban 5 mg twice daily fo… | MyMerci
Adverse Effects/Contraindications/InteractionsPA
Question
A 78-year-old client on chronic apixaban 5 mg twice daily for atrial fibrillation falls and is found to have an acute intracranial hemorrhage on head CT. The last apixaban dose was 6 hours ago. The provider plans urgent reversal. Which order does the nurse anticipate as the priority?
1Idarucizumab (Praxbind) 5 g IV in two consecutive 2.5 g doses.
2Vitamin K 10 mg slow IV every 12 hours for 3 days.
3Hold apixaban; administer andexanet alfa (Andexxa) per institutional protocol — typically high-dose protocol given the recent dose and major bleed (800 mg IV bolus over ~30 minutes followed by 8 mg/min infusion up to 120 minutes); if andexanet alfa is unavailable, give 4-factor prothrombin complex concentrate (PCC) approximately 50 IU/kg; provide concurrent supportive care (BP control, neurosurgery consult, monitoring for thrombosis).✓ Correct answer
4Resume apixaban at half dose to maintain stroke prevention.
Explanation
Andexanet alfa — Xa inhibitor reversal Andexanet alfa (Andexxa) is a recombinant modified, inactive factor Xa decoy that binds and sequesters direct Xa inhibitors (apixaban, rivaroxaban, edoxaban). It is FDA-approved for life-threatening or uncontrolled bleeding in patients on apixaban or rivaroxaban.
Dosing protocol depends on (a) which DOAC, (b) the dose given, and (c) time since the last dose: • Low-dose protocol (400 mg bolus + 4 mg/min for up to 120 min): apixaban ≤5 mg or rivaroxaban ≤10 mg, OR last dose ≥8 hours ago / unknown. • High-dose protocol (800 mg bolus + 8 mg/min for up to 120 min): apixaban >5 mg or rivaroxaban >10 mg given within the past 8 hours.
This client took apixaban 5 mg 6 hours ago. Most institutions select high-dose protocol for major intracranial bleed within 8 hours (some protocols choose by time alone, others by both dose and time — practice site protocols vary).
If andexanet alfa is not available or the institution uses an alternative, 4-factor PCC at 25–50 IU/kg is an accepted off-label alternative supported by guidelines and meta-analyses.
Concurrent priorities: stop apixaban, neurosurgery consult, BP control (target SBP
In-depth explanation
Clinical reasoning summary Andexanet alfa — Xa inhibitor reversal Andexanet alfa (Andexxa) is a recombinant modified, inactive factor Xa decoy that binds and sequesters direct Xa inhibitors (apixaban, rivaroxaban, edoxaban). It is FDA-approved for life-threatening or uncontrolled bleeding in patients on apixaban or rivaroxaban.
Dosing protocol depends on (a) which DOAC, (b) the dose given, and (c) time since the last dose: • Low-dose protocol (400 mg bolus + 4 mg/min for up to 120 min): apixaban ≤5 mg or rivaroxaban ≤10 mg, OR last dose ≥8 hours ago / unknown. • High-dose protocol (800 mg bolus + 8 mg/min for up to 120 min): apixaban >5 mg or rivaroxaban >10 mg given within the past 8 hours.
This client took apixaban 5 mg 6 hours ago. Most institutions select high-dose protocol for major intracranial bleed within 8 hours (some protocols choose by time alone, others by both dose and time — practice site protocols vary).
If andexanet alfa is not available or the institution uses an alternative, 4-factor PCC at 25–50 IU/kg is an accepted off-label alternative supported by guidelines and meta-analyses.
Concurrent priorities: stop apixaban, neurosurgery consult, BP control (target SBP