Pulmonary Vascular Disease: Pulmonary Vascular Disease |

Rivaroxaban Treatment Failure From Possible Drug Interaction: A Case Report FREE TO VIEW

Jasleen Kaur, MD; Syed Rizvi, MD; Praful Tewari, MD; Said Tamer, MD; Tabassum Nafsi, MD
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Northside Medical Center, Youngstown, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A501. doi:10.1016/j.chest.2016.02.523
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SESSION TITLE: Pulmonary Vascular Disease

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Rivaroxaban is a factor Xa inhibitor; commonly being used for treatment of venous thromboembolism (VTE) as one of the newer agents. We report a case of DVT and PE while on therapy with Rivaroxaban; suspected to be secondary to a drug interaction.

CASE PRESENTATION: Patient is a 49 years old male with history of hip replacement complicated by development of VTE. He was started on Coumadin which had to be discontinued when he presented with hip infection and had to return to surgery. He was then treated with Rifampicin and Bactrim for staph aureus infection and hospital course was further complicated by development of another DVT in upper extremity. He was subsequently started on rivaroxaban; but presented 30 days later with shortness of breath and was found to have a saddle embolus on CT chest. He reported strict adherence to medications including his antibiotics. He was successfully treated with Warfarin and later remained symptom free.

DISCUSSION: Rivaroxaban is one of the newer agents that has revolutionized the approach to treatment of VTE in recent years. Bioavailability of Rivaroxaban is dose dependent and the metabolism of rivaroxaban is mediated by CYP3A4. Beside the drug interactions submitted to the FDA by manufacturers, there is paucity of published trials or case reports of drug interactions especially between Rifampin (a CYP3A4 inducer) and Rivaroxaban. Our case highlights a critical issue pertaining to use of Rivaroxaban and use of CYP3A4 inducer. Although, our patient had no apparent contra-indication to use of rivaroxaban; he was on Rifampin for hip infection which may have decreased the concentration of Rivaroxaban. Although dose adjustment is suggested; higher dose of Rivaroxaban is not approved by FDA at this time. The indication for monitoring of drug levels of newer anticoagulants remains a matter of ongoing discussion and target therapeutic ranges are not established nor validated. While traditional anticoagulant, warfarin, is also reported to have several drug interactions; the ability to monitor its effect makes it a reasonable option.

CONCLUSIONS: Rivaroxaban has a comparable safety and efficacy profile when compared to traditional anticoagulants however lack of quantitative assessment of anticoagulation with rivaroxaban makes it a challenge; especially with co-administration of CYP3A4 inhibitors; In such circumstances, traditional anticoagulation with warfarin may be a better choice in patients with potential drug interactions as it allows to monitor effectiveness of therapy.

Reference #1: Abrams PJ et al. Rivaroxaban A Novel Oral direct Factor XA Inhibitor. Pharmacotherapy, 2009, 29 (2) 167-81

Reference #2: Asmis LM et al. Rivoxaban quanttfication by anti FXa Assay and Influence on Coagulation tests. A study in a Swiss labrotories “Throm Res 2012 129 (4) 429 -8

Reference #3: Barrett YC et al. “clinical Labrotory Measurement of direct factor XA Inhibitor: anti Xa assay is preferable to Prothrombin time assay ” thromb Haemost 2010, 104 (6) 1263 -71

DISCLOSURE: The following authors have nothing to disclose: Jasleen Kaur, Syed Rizvi, Praful Tewari, Said Tamer, Tabassum Nafsi

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