Massive Apixaban Overdose Confirmed with Blood Concentrations and Managed Without Bleeding: A Single Case Report

Author:

Harmouche Elie1ORCID,Stueve Peter2,Howland Mary Ann34,Su Mark K4

Affiliation:

1. Department of Emergency Medicine, Division of Medical Toxicology, Maimonides Medical Center, Brooklyn, NY, USA

2. Department of Emergency Medicine, Lincoln Medical Center, Bronx, NY, USA

3. St. John’s University College of Pharmacy and Health Sciences, Jamaica, NY, USA

4. New York City Poison Control Center, Department of Health and Mental Hygiene, New York, NY, USA

Abstract

Background Acute overdoses of apixaban, and other direct oral anticoagulants are relatively uncommon. The number of direct oral anticoagulants prescriptions in the United States is increasing, however reports on patient outcomes after documented overdose are sparse. Case report A 76-year-old man with a past medical history of atrial fibrillation and taking apixaban 5 mg twice daily presented to the emergency department 10 hours after reportedly ingesting 60-70 of his pills. He was alert and had a normal physical examination. Blood tests demonstrated an INR of 12, platelets of 161 000 cells/mm3, hemoglobin 9.7 g/dL, and creatinine 1.81 mg/dL. He received 60 g of activated charcoal and 4 units of fresh frozen plasma prophylactically. Initial blood apixaban concentration was 4 000 ng/mL. Repeat blood apixaban concentrations were 3 000 ng/mL and 2 200 ng/mL at 7 and 14 hours, respectively (thrapeutic range 91-321 ng/mL for a 5 mg twice daily dose). The hybrid anti-factor Xa activity did not correlate with blood apixaban concentrations. Apixaban elimination followed first-order kinetics with an apparent elimination half-life of 14 hours in the presence of impaired renal function. He did not have any minor or major bleeding events.

Publisher

SAGE Publications

Subject

Pharmacology (medical)

Reference17 articles.

1. Lopes RD, Alexander JH, Al-Khatib SM, et al. Apixaban for reduction in stroke and other Thromboembolic events in atrial fibrillation (ARISTOTLE) trial: Design and rationale. Am Heart JAm Heart J. 2010;159159:3311162-339. [Erratum, 2010;].

2. Oral Anticoagulant Utilization in the United States and United Kingdom

3. The X factor: Lack of bleeding after an acute apixaban overdose

4. Anti-Xa activity in apixaban overdose: a case report

5. Massive apixaban overdose – A comparison of three cases

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