Apixaban Overdose with Massive Bleeding and Anti-Xa Levels

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Apixaban overdose with massive bleeding (n=1). Intervention: Apixaban. Primary outcome: Clinical recovery and anti-Xa elimination kinetics.

Q: What does this research mean for the field?

Massive apixaban overdose can cause life-threatening hemorrhage that is manageable with FEIBA and transfusion, and anti-Xa levels demonstrate first-order elimination kinetics even at markedly supratherapeutic concentrations. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Rebecca Kusko; Jami Hagemann; Daniel McCabe; Joshua Trebach

doi:10.1007/s13181-026-01137-5

April 13, 2026Journal of Medical ToxicologyOpen Access

Apixaban Overdose with Massive Bleeding and Anti-Xa Levels

View Full Paper

Ask AI

Bookmark

Share

Key result

FEIBA and transfusion successfully manage life-threatening hemorrhage from massive apixaban overdose with first-order anti-Xa elimination.

n=1

Figures

Why the study?

Factor Xa inhibitor overdoses are rarely reported, clinically relevant bleeding is often absent, and drug level behavior in overdose is not fully agreed on.

Key Points

To describe the clinical management, hemostatic outcomes, and pharmacokinetic elimination pattern of a massive apixaban overdose presenting with life-threatening hemorrhage.
Evaluated a 70-year-old male who ingested at least 250 mg of apixaban alongside acetaminophen, ibuprofen, and wart removal solution, presenting with gastrointestinal hemorrhage and subdural hematoma.
Administered aggressive resuscitation consisting of 1 gram tranexamic acid, 5416 units of anti-inhibitor coagulant complex (FEIBA), 10 mg vitamin K, and a massive transfusion protocol.
Monitored serial anti-Xa levels across hospitalization until concentrations became undetectable.
Anti-Xa concentration measured 1498 ng/mL at 10.0 hours post-overdose and declined across serial measurements (1138.5 ng/mL at 19.1 hours, 834 ng/mL at 26.0 hours, 389 ng/mL at 39.0 hours, 157 ng/mL at 56.1 hours, 76 ng/mL at 63.5 hours, and 25 ng/mL at 82.1 hours).
Elimination kinetics approximated a first-order decay pattern despite markedly supratherapeutic concentrations.
Hemostasis was successfully achieved after resuscitation and reversal therapy, with no further bleeding episodes observed.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

70-year-old male presenting with a polysubstance overdose including at least 250 mg of apixaban, complicated by massive gastrointestinal hemorrhage and parafalcine and tentorial subdural hematoma (n=1).

I

Intervention

1 gram tranexamic acid (TXA), anti-inhibitor coagulant complex (FEIBA), and massive transfusion.

O

Outcome

Cessation of bleeding and pattern of anti-Xa level elimination.

Life-threatening hemorrhage from massive apixaban overdose can be successfully managed with aggressive supportive care including TXA and FEIBA, with the drug exhibiting first-order elimination kinetics.

Limitations

Single case report limiting generalizability
Cannot rule out additional trauma or preexisting gastrointestinal pathology contributing to bleeding
Anti-Xa levels measured using in-house calibration rather than a verified standard
Patient-provided history regarding dose and timing may be unreliable

Implication

May support FEIBA for life-threatening apixaban hemorrhage; hypothesis-generating for first-order elimination kinetics in overdose.

Abstract

Introduction While use of factor Xa inhibitors has increased, there are relatively few cases of overdose reported. Clinically relevant bleeding is often absent, and the behavior of drug levels in overdose is not fully agreed on. Case Report A 70-year-old male presented after a polysubstance overdose including at least 250 mg of apixaban with massive gastrointestinal (GI) hemorrhage and parafalcine and tentorial subdural hematoma. He was treated with 1 gram tranexamic acid (TXA), anti-inhibitor coagulant complex (FEIBA), and massive transfusion. No further episodes of bleeding were observed. Anti-Xa levels were trended until undetectable. Discussion Bleeding from an overdose of factor Xa inhibitors is a relatively rare occurrence; however, this case illustrates that life threatening hemorrhage can occur and may require aggressive supportive care. Anti-Xa levels demonstrated a first order pattern of elimination even at markedly supratherapeutic concentrations, consistent with several prior case reports.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Kusko et al. (2026) conducted a case report in Apixaban overdose with massive bleeding (n=1). Apixaban was evaluated on Clinical recovery and anti-Xa elimination kinetics. A massive apixaban overdose (≥250 mg) causing life-threatening hemorrhage was successfully managed with FEIBA and transfusion, while anti-Xa levels demonstrated first-order elimination kinetics.

synapsesocial.com/papers/69df2ae6e4eeef8a2a6afe10 https://doi.org/10.1007/s13181-026-01137-5

Topics

PCSK9 inhibitors

View Full Paper

Ask AI

Bookmark

Share

Apixaban Overdose with Massive Bleeding and Anti-Xa Levels

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Apixaban Overdose with Massive Bleeding and Anti-Xa Levels

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Keep reading

Topics

Keep reading