Non-vitamin K oral anticoagulant (NOAC) therapy may be inappropriate if prescription was incorrect, the patient’s physiological parameters change, or interacting concomitant medications are erroneously added. The aim of this report was to illustrate inappropriate NOAC prescription in a 78-year-old woman with non-valvular atrial fibrillation and borderline renal dysfunction who was switched from warfarin to rivaroxaban and subsequently developed bruising with hemorrhagic shock and acute on chronic renal failure. Administration of 4-factor prothrombin complex concentrate effectively reversed coagulopathy and stopped bleeding. Retrospective determination of circulating plasma levels of rivaroxaban and warfarin confirmed that excessive anticoagulation was likely due to warfarin that the patient probably continued to take although rivaroxaban was initiated. Pharmacodynamic interaction between rivaroxaban and warfarin may not only be additive but synergistic. In patients at high risk of complications, judicious prescribing and dosing of NOACs, and regular monitoring of concomitant medications and renal function are highly recommended.
An 18-year-old adolescent male presented to our emergency department complaining of chest pain that started about 2 days earlier and remained unchanged. Chest x-rays revealed a right apical pneumothorax. The patient did not use any medication. Two months earlier he had presented to the emergency department with a similar episode that resolved spontaneously. Blood testing performed at the time of presentation showed severe hypokalemia with a potassium concentration of 2.5 mmol/L. He was admitted to our respiratory unit.He was 180 cm (70.9 in) tall and weighed 64 kg (141 lb, body max index 19.8 kg/m 2 ). He was in good general health, and the physical examination was unremarkable. A renal ultrasound was normal. He noted an unintentional weight loss of 7 kg (15.4 lb) over the last 36 months. Furthermore, he reported fatigue and muscle weakness. His personal history and family history were unremarkable. He was delivered naturally at term and developed normally during childhood and puberty.Further blood tests revealed moderate hypomagnesemia of 1.2 mg/dL [0.5 mmol/L; reference interval 1.7-2.2 mg/dL (0.7-0.9 mmol/L)]. Arterial blood gas analysis showed metabolic alkalosis (pH 7.46, bicarbonate 28.9 mmol/L). Sodium, chloride, and calcium were within reference intervals. Renal function, fasting blood glucose, and a complete blood count were normal. Table 1 provides a selection of relevant laboratory results at presentation and during follow-up.As recommended by the British Thoracic Society, the patient was scheduled for video-assisted thoracoscopic surgery (1 ). Before surgery, an endocrine specialist was consulted to further investigate the cause of the patient's hypokalemia and hypomagnesemia. The spontaneous pneumothorax was unrelated to the abnormal electrolyte results and is not further discussed here. The patient's pronounced hypokalemia and hypomagnesemia were initially treated with potassium canrenoate, potassium chloride, and magnesium (Fig. 1). With this therapy, serum potassium improved and stabilized at 2.8 -2.9 mmol/L. Subsequently, amiloride was added to the patient's therapy, which led to a further improvement of serum potassium. However, he reported increasing fatigue, which led to the discontinuation of potassium canrenoate, without which correction of potassium was insufficient. Therefore, it was decided to replace amiloride by potassium canrenoate and spironolactone. Three months after the initial presentation, his potassium had risen to 3.4 mmol/L.Within 10 weeks after the initiation of spironolactone therapy, he developed gynecomastia, a well-known side effect of this drug. Consequently, spironolactone was again replaced by amiloride, although at a higher dose. As serum potassium remained low, at approximately 2.8 mmol/L, he was switched from amiloride to eplerenone, a mineralocorticoid receptor antagonist that does not cause gynecomastia. Potassium and magnesium supplementation were continued as before. With this therapy, serum potassium and magnesium concentrations stabilized near the lower limi...
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