Song Zikai, Wu Haidi, Cao Hongyan, Yang Shuo, Tang Minglong, Qin Ling
Department of Cardiology, the First Hospital of Jilin University, Changchun, China.
Medicine (Baltimore). 2018 Nov;97(45):e13104. doi: 10.1097/MD.0000000000013104.
Rivaroxaban is a non-vitamin K antagonist oral anticoagulant. Current recommendations state that coagulation monitoring is not required, and neither the dose nor dosing interval requires adjustment in response to changes in coagulation parameters when rivaroxaban is used for approved indications. Guidelines mainly discuss the indications for rivaroxaban and non-vitamin K antagonist oral anticoagulants in general; they offer less guidance regarding how to use these medications in specific clinical situations to bridge the gulf between guidelines and clinical practice.
An 88-year-old man with a long history of atrial fibrillation presented to the hospital with worsening dyspnea and chest pain. Significantly, he had an estimated glomerular filtration rate of 46.7 mL/min. He was prescribed oral rivaroxaban 20 mg once daily. After 7 days, the patient complained of maroon colored stools.
Laboratory investigations revealed that the patient's prothrombin time (PT) and activated partial thromboplastin time (aPTT) were elevated. Rivaroxaban induced gastrointestinal bleeding was suspected.
Rivaroxaban was discontinued and routine coagulation tests were monitored daily.
Two days following the discontinuation of the drug, the bleeding was controlled and hemoglobin was normal, but the PT and aPTT remained abnormal. On the third day after discontinuing rivaroxaban, the patient experienced sudden syncope and pulselessness and expired.
This case indicates that in real-world situations, a small number of patients may develop changes in both PT and aPTT during rivaroxaban therapy. Therefore, coagulation monitoring should be considered in patients with risk factors for bleeding, such as elderly patients with renal insufficiency.
利伐沙班是一种非维生素K拮抗剂口服抗凝药。当前建议指出，使用利伐沙班治疗获批适应症时无需进行凝血监测，且剂量和给药间隔均无需根据凝血参数变化进行调整。指南主要讨论了利伐沙班及一般非维生素K拮抗剂口服抗凝药的适应症；但对于如何在特定临床情况下使用这些药物以弥合指南与临床实践之间的差距，提供的指导较少。
一名88岁有长期房颤病史的男性因呼吸困难和胸痛加重入院。重要的是，他的估算肾小球滤过率为46.7毫升/分钟。他被处方每日口服一次利伐沙班20毫克。7天后，患者主诉排暗红色大便。
实验室检查显示患者的凝血酶原时间（PT）和活化部分凝血活酶时间（aPTT）升高。怀疑为利伐沙班所致胃肠道出血。
停用利伐沙班并每日监测常规凝血试验。
停药两天后，出血得到控制且血红蛋白正常，但PT和aPTT仍异常。停用利伐沙班第三天，患者突然晕厥、脉搏消失并死亡。
该病例表明，在实际临床中，少数患者在利伐沙班治疗期间可能出现PT和aPTT均发生变化的情况。因此，对于有出血风险因素的患者，如老年肾功能不全患者，应考虑进行凝血监测。
