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Apixaban Overdose with Massive Bleeding and Anti-Xa Levels
Rebecca Kusko1,2, Jami Hagemann3, Daniel McCabe3,4,5
1Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA. Rebecca-kusko@uiowa.edu.
Summary
Overdosing on apixaban (a factor Xa inhibitor) can cause severe bleeding, requiring aggressive treatment. Drug levels decrease predictably, even at high doses, aiding in patient management.
Area of Science:
- Pharmacology
- Toxicology
- Internal Medicine
Background:
- Factor Xa inhibitors, like apixaban, are increasingly used.
- Overdose cases are rare, with unclear bleeding risk and drug level behavior.
Purpose of the Study:
- To report a case of massive bleeding following a significant apixaban overdose.
- To analyze the elimination kinetics of apixaban at supratherapeutic levels.
Main Methods:
- A 70-year-old male with polysubstance overdose, including >250 mg apixaban, presented with severe GI hemorrhage and subdural hematoma.
- Treatment involved tranexamic acid (TXA), anti-inhibitor coagulant complex (FEIBA), and massive transfusion.
- Serial anti-Xa levels were monitored until undetectable.
Main Results:
- The patient experienced no further bleeding after aggressive treatment.
- Apixaban elimination followed a first-order pattern, even at markedly supratherapeutic concentrations.
Conclusions:
- Life-threatening hemorrhage can occur with factor Xa inhibitor overdose, necessitating intensive supportive care.
- Apixaban elimination kinetics are predictable, even in overdose scenarios.
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