A 77‐year‐old female presented with sudden onset hemoptysis and shortness of breath. She reported a slight cough the night prior that she treated with a cough drop. She went to bed without any problems, but awoke the next day with hemoptysis and breathing difficulties. She has a history of atrial fibrillation, which was recently treated with pulmonary vein ablation and subsequently placed on rivaroxaban for prophylaxis. She denied any fever or chills, chest pain, back pain or abdominal pain. She denied any recent sick contacts, long travel or periods of immobility. Imaging with a CT scan of the chest was remarkable for a left upper lobe infiltrate. Laboratory studies showed a normal white cell count of 6.5, hemoglobin and hematocrit of 8.8 and 26.7, a platelet of 104,000, PTT of 31.2, PT of 16.3, and INR of 1.4. Upon presentation, she had saturations of 95% on room air, respiratory rate of 16, temperature of 97.2, and a blood pressure of 110/57. However, her symptoms became progressive throughout the day and required more oxygen to keep saturations at appropriate levels. Her initial trace amount of blood with coughing became frank hemoptysis, she soon decompensated and a code was initiated. She was intubated and a prolonged ACLS protocol was performed with return of pulse. The patient had blood return continuously from the ET tube. She was aggressively transfused with a total of 12 units of packed red blood cell, 6 units of fresh frozen plasma, and 4 units of pooled platelets and administered activated prothrombin complex concentrates (FEIBA). Even with these aggressive measures, the bleeding did not stop. The patient again coded and expired.
Rivaroxaban is an orally available direct factor Xa inhibitor indicated for the treatment and prevention of venous thrombo‐ embolism and risk reduction for stroke in non‐valvular atrial fibrillation. The clinical advantage of this newer agent compared to warfarin and heparin based products is that it is orally available, has ease of standardized dosing and no requirement for monitoring. The use of rivaroxaban is not recommended for any patient with significant hepatic impairment, and those with a creatinine clearance <30 mL/min and is contraindicated in those with a creatinine clearance <15 mL/min. The major disadvantages of this drug, along with all newer drugs in this class, are cost and the inability to reverse its effects. In the event of hemorrhage, standard measures must be employed, but there is no specific antidote. This drug is mostly protein bound; therefore, it cannot be dialyzed out. In a preliminary study, FEIBA was reported to correct the bleeding time in baboons treated with rivaroxaban. Finally, the use of unactivated or activated prothrombin complex concentrates (PCC) has been suggested, but this has never been tested in humans.
Direct factor Xa inhibitors are rapidly being adopted as a safe and effective alternative to treatment with warfarin and heparin products. As hospitalists, we are having an increasing number of patients coming into the hospital setting on these new medications and we are also initiating treatment with these agents as well. We must be mindful of the risk and benefit to the patient, and be aware of the contraindication in the setting of renal and hepatic impairment. Finally, there is no reversal agent for any of these new drugs. Therefore, protocols should be in place in the event of major hemorrhage.
To cite this abstract:Choe E. A Cautionary Tale. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 387. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/a-cautionary-tale/. Accessed March 28, 2020.