A Rare Case of Rivaroxaban Causing Delayed Symptomatic Hepatocellular Injury and Hyperbilirubinemia

Abstract

Importance. As Rivaroxaban has increased in popularity, it has been accompanied with a growing body of evidence displaying its ability to cause drug induced liver injury (DILI). Observation. A 74-year-old Caucasian female developed Rivaroxaban DILI two weeks after finishing a 14-day course. The patient was symptomatic and jaundiced with elevated transaminases and hyperbilirubinemia with normal lab values two months priorly. Liver biopsies showed mixed inflammatory infiltrate of lymphocytes, neutrophils and eosinophils, rare necrotic hepatocytes, and canalicular and intrahepatocellular cholestasis, all of which are consistent with DILI. Conclusion and Relevance. We present this case to add to the growing evidence that Rivaroxaban can be associated with severe, symptomatic liver injury and to ensure physicians are aware of these possible side effects of novel anticoagulants with their increasing use.

Hepatotoxicity of New Oral Anticoagulants

“…После этого были также исключены статьи, в которых не приводятся описания конкретных клинических случаев, итого -в обзор включено 14 статей (рис. 1) [14,15,[17][18][19][20][21][22][23][25][26][27][28][29].…”

“…Следует обратить внимание, что практически во всех случаях развития гепатотоксичности купирование лабораторных симптомов происходило после отмены ривароксабана, без применения дополнительной терапии. Нормализация лабораторных показателей и купирование клинических проявлений обычно происходило через неделю после отмены ЛС [18][19][20][21]. Возможные механизмы вызванной ривароксабаном гепатотоксичности неизвестны и, вероятно, включают сложные взаимодействия нескольких редких факторов и иммунно-опосредованных реакций.…”

Non-hemorrhage-related adverse effects of rivaroxaban

“…In the majority of these cases liver injury was classified as hepatocellular (approximately 40%), whereas in the other cases the pattern was cholestatic (approximately 27%) or mixed (approximately 15%) [ 17 ]. The severity of hepatotoxicity ranged from asymptomatic liver injury with a cholestatic pattern [ 18 ] to symptomatic and severe [ 19 – 26 ]. Some of the symptomatic patients developed jaundice and nausea [ 20 , 22 , 26 ] and 1 patient developed acute liver failure and hepatic encephalopathy with a fatal outcome [ 25 ].…”

Factor Xa Induced Hepatobiliary Dysfunction in an Eastern Asian Male

“…Factor Xa inhibitors, such as Rivaroxaban and Apixaban, are approved for the prevention of clot formation in non-valvular atrial fibrillation and for treating deep venous thromboembolism and pulmonary embolism [1][2][3]. These drugs selectively inhibit the active site of factor Xa and are eliminated by both the liver and the kidney (one-third by the liver and two-thirds by the kidney).…”