Accidental apixaban intoxication in a 23-month-old child: a
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Direct oral anticoagulants, such as apixaban, are increasingly used in everyday practice in order to treat or prevent thromboembolic diseases.

A 23-month-old boy (12.9 Kg), with no medical history, was admitted to the emergency department 2 h after accidentally ingesting 8 pills of apixaban 5 mg and 3 pills of digoxin 0.25 mg. The child remained under medical supervision for 48h.

Four blood tests were withdrawn during hospitalization at 2, 6, 21.5 and 48h after the ingestion, for digoxin concentrations monitoring and routine coagulation assays. Apixaban monitoring was initiated at H + 21.5. Apixaban concentrations were also retrospectively analyzed at H + 2 and H +6. The renal function was normal and remained stable Apixaban concentration increased up to 1712 g/L at H + 6, then decreased to 7 g/L at H + 48.

It was eliminated with a terminal half-life of 8.2 h and its distribution volume indexed to bioavailability was 23 L or 1.8 L/Kg. As expected, aPTT ratio (activated partial thromboplastin time ratio: Patient aPTT (sec) /Normal plasma aPTT (sec)) and PT were prolonged.

Regarding digoxin, the concentration at H + 2 was 5.9g/L and decreased to 0.4g/L at H+48. Digoxin was eliminated with a half-life of approximatively 15.6h. The patient left the hospital after 48h without any complication or sequelae.

Despite an important intake of apixaban and a real disturbance in routine coagulation assays, no clinical sign of bleeding was observed, perhaps due to wide therapeutic range of apixaban. It may also be explained by its rapid elimination. Considering the high Cmax and a possible enteroenteric recycling, the use of activated charcoal should be considered in such situations in order to prevent eventual bleeding.