{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T01:14:04Z","timestamp":1783473244534,"version":"3.55.0"},"reference-count":23,"publisher":"Oxford University Press (OUP)","issue":"14","license":[{"start":{"date-parts":[[2026,3,3]],"date-time":"2026-03-03T00:00:00Z","timestamp":1772496000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,7,8]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>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).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>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\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ajhp\/zxag059","type":"journal-article","created":{"date-parts":[[2026,3,1]],"date-time":"2026-03-01T12:34:06Z","timestamp":1772368446000},"page":"722-727","source":"Crossref","is-referenced-by-count":1,"title":["Adrenal hemorrhage requiring apixaban reversal in the setting of active deep vein thrombosis and heparin-induced thrombocytopenia: A case report"],"prefix":"10.1093","volume":"83","author":[{"given":"Michael","family":"Lichardi","sequence":"first","affiliation":[{"name":"Hackensack Meridian Ocean University Medical Center , Brick, NJ ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shannon","family":"Moriarty","sequence":"additional","affiliation":[{"name":"Hackensack Meridian Ocean University Medical Center , Brick, NJ ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haley","family":"Nicholas","sequence":"additional","affiliation":[{"name":"Hackensack Meridian Ocean University Medical Center , Brick, NJ ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,3,3]]},"reference":[{"key":"2026070720214970900_zxag059-B1"},{"key":"2026070720214970900_zxag059-B2","author":"Andexxa"},{"issue":"13","key":"2026070720214970900_zxag059-B3","doi-asserted-by":"publisher","first-page":"1026","DOI":"10.1161\/CIRCULATIONAHA.121.057844","article-title":"Final study report of andexanet alfa for major bleeding with factor Xa inhibitors","volume":"147","author":"Milling","year":"2023","journal-title":"Circulation"},{"issue":"19","key":"2026070720214970900_zxag059-B4","doi-asserted-by":"publisher","first-page":"1745","DOI":"10.1056\/NEJMoa2313040","article-title":"Andexanet for factor Xa inhibitor-associated acute intracerebral hemorrhage","volume":"390","author":"Connolly","year":"2024","journal-title":"N Engl J Med"},{"issue":"6","key":"2026070720214970900_zxag059-B5","doi-asserted-by":"publisher","first-page":"697","DOI":"10.1002\/ajh.25475","article-title":"Reversal of direct oral anticoagulants: guidance from the Anticoagulation Forum","volume":"94","author":"Cuker","year":"2019","journal-title":"Am J Hematol"},{"key":"2026070720214970900_zxag059-B6","author":"Balfaxar","year":"2024"},{"key":"2026070720214970900_zxag059-B7","volume-title":"StatPearls","author":"Mehmood","year":"2023"},{"key":"2026070720214970900_zxag059-B8","doi-asserted-by":"publisher","first-page":"CD007557","DOI":"10.1002\/14651858.CD007557.pub2","article-title":"Unfractionated heparin versus low molecular weight heparin for avoiding heparin-induced thrombocytopenia in postoperative patients","volume":"9):","author":"Junqueira","year":"2012","journal-title":"Cochrane Database Syst Rev"},{"issue":"22","key":"2026070720214970900_zxag059-B9","doi-asserted-by":"publisher","first-page":"3360","DOI":"10.1182\/bloodadvances.2018024489","article-title":"American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia","volume":"2","author":"Cuker","year":"2018","journal-title":"Blood Adv"},{"issue":"19","key":"2026070720214970900_zxag059-B10","doi-asserted-by":"publisher","first-page":"4693","DOI":"10.1182\/bloodadvances.2020001830","article-title":"American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism","volume":"4","author":"Ortel","year":"2020","journal-title":"Blood Adv"},{"key":"2026070720214970900_zxag059-B11","doi-asserted-by":"publisher","first-page":"1233710","DOI":"10.3389\/fendo.2023.1233710","article-title":"Bilateral adrenal hemorrhage: learning notes from clinical practice and literature review","volume":"14","author":"Aloini","year":"2023","journal-title":"Front Endocrinol"},{"issue":"1","key":"2026070720214970900_zxag059-B12","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1186\/s12959-022-00397-9","article-title":"Adrenal hemorrhage following direct oral anticoagulant (DOAC) therapy: two case reports and literature review","volume":"20","author":"Sheklabadi","year":"2022","journal-title":"Thromb J"},{"issue":"12","key":"2026070720214970900_zxag059-B13","doi-asserted-by":"publisher","first-page":"1145","DOI":"10.1016\/j.ijscr.2014.09.033","article-title":"Post-operative bilateral adrenal haemorrhage: a case report","volume":"5","author":"McNicol","year":"2014","journal-title":"Int J Surg Case Rep"},{"key":"2026070720214970900_zxag059-B14","doi-asserted-by":"publisher","first-page":"336","DOI":"10.1016\/j.ijscr.2020.12.028","article-title":"Bilateral adrenal hemorrhage after colectomy for perforated diverticulitis: a case report","volume":"78","author":"Esparza Monzavi","year":"2021","journal-title":"Int J Surg Case Rep"},{"issue":"4","key":"2026070720214970900_zxag059-B15","doi-asserted-by":"publisher","first-page":"833","DOI":"10.1097\/CCM.0b013e318206d0eb","article-title":"Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia","volume":"39","author":"Rosenberger","year":"2011","journal-title":"Crit Care Med"},{"key":"2026070720214970900_zxag059-B16","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1016\/j.ajem.2025.07.037","article-title":"Andexanet alfa increases 30-day thrombotic events relative to four-factor prothrombin complex concentrate for factor Xa inhibitors-related intracerebral hemorrhage in veterans","volume":"97","author":"Rech","year":"2025","journal-title":"Am J Emerg Med"},{"issue":"22","key":"2026070720214970900_zxag059-B17","doi-asserted-by":"publisher","first-page":"3257","DOI":"10.1182\/bloodadvances.2018024893","article-title":"American Society of Hematology. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy","volume":"2","author":"Witt","year":"2018","journal-title":"Blood Adv"},{"key":"2026070720214970900_zxag059-B18","author":"FEIBA"},{"key":"2026070720214970900_zxag059-B19"},{"issue":"4","key":"2026070720214970900_zxag059-B20","doi-asserted-by":"publisher","first-page":"103","DOI":"10.3390\/medicines6040103","article-title":"Direct-acting oral anticoagulants and their reversal agents\u2014an update","volume":"6","author":"Kustos","year":"2019","journal-title":"Medicines"},{"issue":"1","key":"2026070720214970900_zxag059-B21","doi-asserted-by":"publisher","first-page":"32","DOI":"10.1007\/s11239-015-1317-0","article-title":"Guidance for the treatment of deep vein thrombosis and pulmonary embolism","volume":"41","author":"Streiff","year":"2016","journal-title":"J Thromb Thrombolysis"},{"issue":"8","key":"2026070720214970900_zxag059-B22","doi-asserted-by":"publisher","first-page":"e2329729","DOI":"10.1001\/jamanetworkopen.2023.29729","article-title":"Sepsis prediction model for determining sepsis vs SIRS, qSOFA, and SOFA","volume":"6","author":"Schertz","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"4","key":"2026070720214970900_zxag059-B23","doi-asserted-by":"publisher","first-page":"e0266755","DOI":"10.1371\/journal.pone.0266755","article-title":"A comparison of qSOFA, SIRS and NEWS in predicting the accuracy of mortality in patients with suspected sepsis: a meta-analysis","volume":"17","author":"Wang","year":"2022","journal-title":"PLoS One"}],"container-title":["American Journal of Health-System Pharmacy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article-pdf\/doi\/10.1093\/ajhp\/zxag059\/67220331\/zxag059.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ajhp\/article-pdf\/83\/14\/722\/67220331\/zxag059.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ajhp\/article-pdf\/83\/14\/722\/67220331\/zxag059.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:21:54Z","timestamp":1783470114000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ajhp\/article\/83\/14\/722\/8505553"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,3]]},"references-count":23,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2026,3,3]]},"published-print":{"date-parts":[[2026,7,8]]}},"URL":"https:\/\/doi.org\/10.1093\/ajhp\/zxag059","relation":{},"ISSN":["1079-2082","1535-2900"],"issn-type":[{"value":"1079-2082","type":"print"},{"value":"1535-2900","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,7,15]]},"published":{"date-parts":[[2026,3,3]]}}}