Adrenal hemorrhage requiring apixaban reversal in the setting of active deep vein thrombosis and heparin-induced thrombocytopenia: A case report

PURPOSE: To describe the management challenges of bilateral adrenal hemorrhage (BAH) in a patient on apixaban with recent heparin-induced thrombocytopenia (HIT) and active deep vein thrombosis (DVT). SUMMARY: A 71-year-old woman with a history of orthopedic trauma developed HIT during hospitalization and was transitioned to fondaparinux. She was later discharged on apixaban for treatment of a provoked left common femoral DVT. Within 48 hours, she presented with shock initially attributed to sepsis. Computed tomography revealed BAH, raising concern for adrenal crisis. Reversal of apixaban was urgently considered but complicated by the patient's active thrombosis and history of HIT, which excluded the use of 4-factor prothrombin complex concentrate and posed challenges to the use of andexanet alfa given institutional policy and the limited data in patients with thrombotic events. After shared decision-making with the patient and family, andexanet alfa was administered given the life-threatening nature of the hemorrhage. The patient stabilized with corticosteroid support, required placement of an inferior vena cava filter, and was later restarted on prophylactic-dose fondaparinux. She was discharged to a skilled nursing facility with recovery of hemodynamic stability. CONCLUSION: This case illustrates the intersection of BAH, active thrombosis, and HIT, where guideline-directed reversal strategies are limited. It underscores the challenges of selecting and timing anticoagulation reversal in patients with recent thrombotic events and contraindications to standard agents, highlighting the importance of individualized, interdisciplinary decision-making in managing complex anticoagulation scenarios.