Rivaroxaban and Hemostasis in Emergency Care

Abstract

Rivaroxaban is an oral, direct Factor Xa inhibitor, approved for the prevention and treatment of several thromboembolic disorders. Rivaroxaban does not require routine coagulation monitoring and has a short half-life. However, confirmation of rivaroxaban levels may be required in circumstances such as life-threatening bleeding or perioperative management. Here, we explore the management strategies in patients receiving rivaroxaban who have a bleeding emergency or require emergency surgery. Rivaroxaban plasma concentrations can be assessed quantitatively using anti-Factor Xa chromogenic assays, or qualitatively using prothrombin time assays (using rivaroxaban-sensitive reagents). In patients receiving long-term rivaroxaban therapy who require elective surgery, discontinuation of rivaroxaban 20–30 hours beforehand is normally sufficient to minimize bleeding risk. For emergency surgery, we advise against prophylactic use of hemostatic blood products, even with high rivaroxaban concentrations. Temporary rivaroxaban discontinuation is recommended if minor bleeding occurs; for severe bleeding, rivaroxaban withdrawal may be necessary, along with compression or appropriate surgical treatment. Supportive measures such as blood product administration might be beneficial. Life-threatening bleeding demands comprehensive hemostasis management, including potential use of agents such as prothrombin complex concentrate. Patients taking rivaroxaban who require emergency care for bleeding or surgery can be managed using established protocols and individualized assessment.

Rivaroxaban-induced chest wall spontaneous expanding hematoma

“…The other one-third is excreted unchanged by the kidneys (1). Rivaroxaban, however, is contraindicated in patients with severe renal impairment and in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk (1).…”

“…In addition, no prospective randomized clinical trials for patients presenting with acute bleeding have been conducted (1).…”

“…In cases of severe bleeding discountinuation of rivaroxaban along with compression or appropriate surgical or interventional treatment are necesseary, while for life threatening bleeding the use of prothrombin complex concetrate is needed (1). In a recent study andexanet alfa, a recombinant modified human factor Xa decoy protein, reduced the anti-factor Xa activity by 92% in a series of 27 healthy older rivaroxaban treated…”

“…Rivaroxaban is an oral direct Factor Xa inhibitor that has been approved for the prevention of venous thromboembolism in patients undergoing elective hip or knee replacement surgery, for stroke prevention in patients with nonvalvular atrial fibrilation and for the treatment and secondary prevention of recurrent deep vein thrombosis and pulmonary embolism (1,2). Bleeding is the most common complication of anticoagulant therapy (3).…”

Bleeding associated with coadministration of rivaroxaban and clarithromycin

“…For patients with major bleeding, some experts recommend the use of antifibrinolytic agents (e.g., tranexamic acid, ε-aminocaproic acid). 11 For life-threatening bleeding, nonspecific hemostatic agents such as fourfactor prothrombin complex concentrate are recommended, on the basis of expert opinion and small randomized controlled trials. 11 However, treatment with prothrombin complex concentrates is associated with a marked prothrombotic risk and should be reserved for truly life-threatening bleeding.…”