Heart & Lung 43 (2014) 262e263
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Prolonged anticoagulant activity of rivaroxaban in a polymorbid elderly female with non-convulsive epileptic state Claudia Stöllberger, MD *, Josef Finsterer, MD Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien, Austria
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 February 2014 Received in revised form 3 March 2014 Accepted 4 March 2014
Objectives and background: Rivaroxaban, an oral direct factor Xa-inhibitor was non-inferior to adjusted dose warfarin in the prevention of stroke and embolism among patients with atrial fibrillation (AF) in the ROCKET-AF trial and has been approved for stroke prevention in AF. Case report: A 88-years-old female (body-mass-index ¼ 19.95) with AF, hypertension and diabetes mellitus, hospitalized because of heart failure and a non-convulsive epileptic state, was treated by valproate, mirtazepin, nebivolol, digitoxin, lisinopril, gliclazide and amlodipine. Irrespective of renal insufficiency, rivaroxaban 15 mg/d was started. After 3 days rivaroxaban was stopped because of concerns about the bleeding risk. Coagulation tests 28 h after rivaroxaban-intake showed INR 2.26, PT 35%, aPTT 38.3 s and anti-Factor Xa-activity 2.00 U/ml. Explanations for the prolonged anticoagulant activity of rivaroxaban comprise renal failure, the low body-mass-index, the advanced age and drugedrug interactions of rivaroxaban with mirtazepin, valproate and amlodipine. Conclusion: Health care providers should consider renal function, concomitant medication, polymorbidity and age prior to prescribing rivaroxaban. Care has to be taken when prescribing rivaroxaban to patients who are different from those included in the ROCKET AF trial. Ó 2014 Elsevier Inc. All rights reserved.
Keywords: Rivaroxaban Atrial fibrillation Renal failure Drug interaction
Introduction In the ROCKET-AF trial rivaroxaban, an oral direct factor Xa inhibitor, was compared with warfarin among patients with nonvalvular atrial fibrillation (AF) who were at moderate-to-high risk of stroke.1 In that randomized trial, 14,264 patients with a median age of 73 years received either dose-adjusted warfarin or 20 mg/ d rivaroxaban. Rivaroxaban was noninferior to warfarin for the prevention of stroke or embolism. Intracranial and fatal bleeding occurred less frequently in the rivaroxaban- than in the warfarintreated patients.1 Based on the results of this study rivaroxaban has been approved for stroke prevention in many countries.2 Important issues like laboratory monitoring, drug-druginteractions and availability of an antidote are not clarified.3
Abbreviations: AF, atrial fibrillation; DOAC, direct anticoagulants; VKA, vitaminK-antagonist. * Corresponding author. Steingasse 31/18, A-1030 Wien, Austria. Tel./fax: þ43 1 945 42 91. E-mail addresses: [email protected], claudia.stoellberger@ wienkav.at (C. Stöllberger). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2014.03.004
These aspects are illustrated by an 88-years-old female who had refused to take vitamin-K-antagonists (VKAs) for stroke prevention.
Case report The patient suffered from AF, arterial hypertension and diabetes mellitus, and she was hospitalized because of generalized weakness, intermittent confusion and increasing dyspnea. After 8 days she developed speech disturbances due to a non-convulsive epileptic state. Valproic acid 1600 mg/24h was initiated on day 9. She was afraid of bleeding during anticoagulant therapy and refused anticoagulation with VKAs. Thus rivaroxaban 15 mg/d was started on day 9 despite renal insufficiency. Additional medication included mirtazepin 15 mg/d, nebivolol 5 mg/d, digitoxin 0.07 mg/ d, lisinopril 10 mg/d, gliclazide 45 mg/d and amlodipine 10 mg/d. Her body weight was 53 kg, her height was 163 cm, and body mass index was 19.95. After she had taken rivaroxaban during three days the medication was stopped on day 11 because of concerns about the bleeding risk. Blood coagulation tests were carried out 28 h after she had taken the last rivaroxaban tablet, and the results are listed in Table 1. Neither clinical findings nor laboratory findings
C. Stöllberger, J. Finsterer / Heart & Lung 43 (2014) 262e263 Table 1 Results of blood tests. Time of blood sampling parameter (reference) BUN, mg/dl (9e20) Creatinine, mg/dl (90)b GFR, ml/min/1.73m2 (>90)c Hemoglobin, g/dl (14e17) Thrombocytes, /nl (150e450) INR PT, % (70e130)d aPTT, sec (
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Prolonged anticoagulant activity of rivaroxaban in a polymorbid elderly female with non-convulsive epileptic state Claudia Stöllberger, MD *, Josef Finsterer, MD Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien, Austria
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 February 2014 Received in revised form 3 March 2014 Accepted 4 March 2014
Objectives and background: Rivaroxaban, an oral direct factor Xa-inhibitor was non-inferior to adjusted dose warfarin in the prevention of stroke and embolism among patients with atrial fibrillation (AF) in the ROCKET-AF trial and has been approved for stroke prevention in AF. Case report: A 88-years-old female (body-mass-index ¼ 19.95) with AF, hypertension and diabetes mellitus, hospitalized because of heart failure and a non-convulsive epileptic state, was treated by valproate, mirtazepin, nebivolol, digitoxin, lisinopril, gliclazide and amlodipine. Irrespective of renal insufficiency, rivaroxaban 15 mg/d was started. After 3 days rivaroxaban was stopped because of concerns about the bleeding risk. Coagulation tests 28 h after rivaroxaban-intake showed INR 2.26, PT 35%, aPTT 38.3 s and anti-Factor Xa-activity 2.00 U/ml. Explanations for the prolonged anticoagulant activity of rivaroxaban comprise renal failure, the low body-mass-index, the advanced age and drugedrug interactions of rivaroxaban with mirtazepin, valproate and amlodipine. Conclusion: Health care providers should consider renal function, concomitant medication, polymorbidity and age prior to prescribing rivaroxaban. Care has to be taken when prescribing rivaroxaban to patients who are different from those included in the ROCKET AF trial. Ó 2014 Elsevier Inc. All rights reserved.
Keywords: Rivaroxaban Atrial fibrillation Renal failure Drug interaction
Introduction In the ROCKET-AF trial rivaroxaban, an oral direct factor Xa inhibitor, was compared with warfarin among patients with nonvalvular atrial fibrillation (AF) who were at moderate-to-high risk of stroke.1 In that randomized trial, 14,264 patients with a median age of 73 years received either dose-adjusted warfarin or 20 mg/ d rivaroxaban. Rivaroxaban was noninferior to warfarin for the prevention of stroke or embolism. Intracranial and fatal bleeding occurred less frequently in the rivaroxaban- than in the warfarintreated patients.1 Based on the results of this study rivaroxaban has been approved for stroke prevention in many countries.2 Important issues like laboratory monitoring, drug-druginteractions and availability of an antidote are not clarified.3
Abbreviations: AF, atrial fibrillation; DOAC, direct anticoagulants; VKA, vitaminK-antagonist. * Corresponding author. Steingasse 31/18, A-1030 Wien, Austria. Tel./fax: þ43 1 945 42 91. E-mail addresses: [email protected], claudia.stoellberger@ wienkav.at (C. Stöllberger). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2014.03.004
These aspects are illustrated by an 88-years-old female who had refused to take vitamin-K-antagonists (VKAs) for stroke prevention.
Case report The patient suffered from AF, arterial hypertension and diabetes mellitus, and she was hospitalized because of generalized weakness, intermittent confusion and increasing dyspnea. After 8 days she developed speech disturbances due to a non-convulsive epileptic state. Valproic acid 1600 mg/24h was initiated on day 9. She was afraid of bleeding during anticoagulant therapy and refused anticoagulation with VKAs. Thus rivaroxaban 15 mg/d was started on day 9 despite renal insufficiency. Additional medication included mirtazepin 15 mg/d, nebivolol 5 mg/d, digitoxin 0.07 mg/ d, lisinopril 10 mg/d, gliclazide 45 mg/d and amlodipine 10 mg/d. Her body weight was 53 kg, her height was 163 cm, and body mass index was 19.95. After she had taken rivaroxaban during three days the medication was stopped on day 11 because of concerns about the bleeding risk. Blood coagulation tests were carried out 28 h after she had taken the last rivaroxaban tablet, and the results are listed in Table 1. Neither clinical findings nor laboratory findings
C. Stöllberger, J. Finsterer / Heart & Lung 43 (2014) 262e263 Table 1 Results of blood tests. Time of blood sampling parameter (reference) BUN, mg/dl (9e20) Creatinine, mg/dl (90)b GFR, ml/min/1.73m2 (>90)c Hemoglobin, g/dl (14e17) Thrombocytes, /nl (150e450) INR PT, % (70e130)d aPTT, sec (
