Pulmonary Vascular Disease: Pulmonary Vascular Disease |

Recurrence of Pulmonary Embolism While on Rivaroxaban: Treatment Failure FREE TO VIEW

Tamer Said Ahmed, MD; Praful Tewari, MD; Jasleen Kaur, MD; Syed Rizvi, 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):A505. doi:10.1016/j.chest.2016.02.527
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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 direct factor Xa inhibitor used for treatment and prevention of venous thromboembolism (VTE). Anticoagulation using a fixed-dose regimen of Rivaroxaban has been shown to be as effective as standard anticoagulant therapy and is an attractive alternative due to its efficacy and lack of requirement of monitoring. We present a case of treatment failure within 2 weeks of Rivaroxaban initiation

CASE PRESENTATION: A 59-year-old obese female presented with progressively worsening shortness of breath (SOB) on exertion for 2 weeks. She had stable hemodynamics with clear lung fields and laboratory data revealed an elevated DDIMER. Radiological imaging confirmed bilateral pulmonary emboli and echocardiogram showed elevated pulmonary pressures. She was given therapeutic dose of enoxaparin and thereafter started on rivaroxaban 15 mg BID. She returned on day 10 with worsening SOB despite strict adherence to medication and follow up imaging showed increased clot burden. She was subsequently treated with warfarin and has since remained symptom free with normalization of pulmonary pressures.

DISCUSSION: Rivaroxaban is non-inferior to traditional anticoagulation in treatment of VTE. It has obvious advantages including its onset of action with half-life of 5-9 hours in healthy young subjects and 11-13 hours in elderly subjects along with limited drug interactions and similar risk of bleeding when compared to enoxaparin/Warfarin. Rivaroxaban was also reported to be better than placebo for preventing recurrence of VTE in the ‘Continued Treatment Study'. While rapid onset of action and lack of monitoring makes this drug an attractive alternative, these may also be its potential disadvantage. The lowest effective daily dose for rivaroxaban in the treatment of VTE was determined as 20 mg daily, although twice a day regimen was recommended to provide better clot resolution during the initial 3 weeks of therapy when risk of recurrence is highest. We report a case of recurrence of VTE within 10 days of therapy while the patient was on twice a day regimen and reported strict adherence. Although our patient was morbidly obese with a BMI of 45, no dose adjustment for obese patients has been recommended thus far. The lack of monitoring makes determination of the efficacy of anticoagulation with rivaroxaban unreliable and our report highlights first such case to be reported.

CONCLUSIONS: Rivaroxaban offers simplification of treatment of VTE and prevention of recurrence. However the benefits of simple oral dosing should be balanced against the lack of monitoring as well as lack of efficacy data, especially in obese patients.

Reference #1: Kubitza D et al. Body weight has limited influence on the safety, tolerability, pharmacokinetics, or pharmacodynamics of rivaroxaban (BAY 59-7939) in healthy subjects. J Clin Pharmacol. 2007;47:218-226

Reference #2: Eikelboom JW et al. New anticoagulants. Circulation. 2010;121:1523-1532.

Reference #3: The EINSTEIN-PE Investigators N Engl J Med 2012; 366:1287-1297

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

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