# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=374983&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## 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? ## Option 1. Hold apixaban; administer idarucizumab (Praxbind) per institutional protocol — 5 g IV push over 5 to 10 minutes in two consecutive 2.5 g doses; if idarucizumab is unavailable, consider activated charcoal if last dose less than 2 hours ago and hemodialysis; provide concurrent supportive care (blood pressure management, neurosurgery evaluation, seizure precautions); monitor for thrombotic complications and repeat neuroimaging if neurological status deteriorates. 2. Hold apixaban; administer vitamin K 10 mg by slow intravenous infusion every 12 hours for 3 days to reverse anticoagulation; if INR remains elevated after 24 hours, consider fresh frozen plasma (FFP) 15 mL/kg; provide supportive care with blood pressure control, neurosurgery consult, and seizure precautions; monitor INR daily, observe for signs of thrombosis or fluid overload, and repeat CT head in 6 hours if neurological status declines. 3. Hold 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** 4. Do not hold apixaban; instead, reduce dose to 2.5 mg twice daily to balance stroke prevention with bleeding risk; administer concurrent prohemostatic agents such as tranexamic acid 1 g IV every 8 hours to promote clot stability; provide supportive care with strict blood pressure control (systolic **Correct answer: 3** ## 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 ## Related questions - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=en) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. 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