Bullous pemphigoid‐like skin rash associated with Rivaroxaban use in a very elderly patient with multimorbidity and chronic kidney disease: A case report

Abstract

Direct oral anticoagulants (DOACs) are increasingly being used in the elderly population in view of its ease of use, efficacy, and favorable side‐effect profile compared with the vitamin K antagonists. However, there is a need for increase awareness of well‐characterized cases, albeit a small number, of bullous pemphigoid‐like skin reactions associated with rivaroxaban.

Rivaroxaban-Associated Bullous Pemphigoid in a Patient With Atrial Fibrillation

“…In our case, as well as in previous case reports, 1 , 5 distinguishing between drug-associated BP and idiopathic BP was difficult. Many cases of drug-associated BP, including the two previous case reports for rivaroxaban-associated BP, present as acute, self-limiting diseases with quick onset and rapid resolution after drug withdrawal.…”

“…We found 2 suspected cases of rivaroxaban-associated BP-like reaction supported by either clinical judgement and/or hematoxylin and eosin histopathology in the English-language literature. 1 , 5 However, to our knowledge, there were no reports with confirmatory immunofluorescence establishing a definitive diagnosis of BP secondary to rivaroxaban exposure, as presented in this report.…”

“…The Naranjo algorithm for adverse drug reaction probability was previously employed by Chohan et al and revealed a “probable” association between rivaroxaban use and BP. 5 In our case, we obtained a score of +5, which indicates a “probable” adverse drug reaction due to rivaroxaban ( Supplemental Table S1 ). An important point to note is that, unlike Chohan et al, we have not attributed points to items 1 and 5, as we do not believe there has been a conclusive prior report of rivaroxaban-induced BP, nor can we exclude idiopathic BP from the differential.…”

“…The Naranjo algorithm for adverse drug reaction probability scale was previously employed by Chohan et al to show a "probable" association between rivaroxaban-use and BP 5 . In our case, we obtained a score of +5 which would indicate "probable" adverse drug reaction due to rivaroxaban (Supplementary Table S1).…”

“…Many cases of drug-associated BP, including the two previous case reports for rivaroxaban-associated BP, present as acute, self-limiting diseases with quick onset and rapid resolution after drug withdrawal. 1 , 2 , 5 However, there have been documented cases of drug-associated BP with more chronic presentations. Specifically, drug eruptions can occur for up to months after the first introduction, and remission can be achieved after weeks to months of oral corticosteroid treatment, similar to the pattern in our case.…”