Would a 74-year-old male with vasculopathy, smoking history, coronary calcifications, history of angioplasty in the lower extremity (LE), severe narrowing of aorticiliac arteries and superior mesenteric artery (SMA), on rosuvastatin (rosuvastatin) and aspirin (acetylsalicylic acid) 81 milligrams daily, experiencing easy bruising as a side effect of clopidogrel (Plavix), benefit from alternative anticoagulants such as rivaroxaban (Xarelto) 2.5 milligrams daily?

From the Guidelines

For this 74-year-old male with extensive vascular disease and history of bleeding with Plavix, continuing aspirin 81mg daily and rosuvastatin for secondary prevention is the most appropriate approach, as adding Xarelto 2.5mg daily would likely increase bleeding risk. The patient's history of easy bruising with Plavix suggests a high bleeding risk, and the use of Xarelto 2.5mg daily in combination with aspirin would further increase this risk 1. According to the 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease, the bleeding risk can be estimated by HAS-BLED or ABC score, and in this case, the patient's bleeding risk is already elevated 1.

The PIONEER AF-PCI study demonstrated that low-dose rivaroxaban (15 mg o.d.) plus a P2Y12 inhibitor (and no ASA) for 12 months had a lower primary safety endpoint of TIMI clinically significant bleeding compared to standard therapy with a dose-adjusted VKA plus DAPT 1. However, this study does not support the use of Xarelto 2.5mg daily as a replacement for Plavix in this patient, as the combination of Xarelto and aspirin would likely increase bleeding risk.

Instead, management should focus on other cardiovascular risk factors like smoking cessation, blood pressure control, and diabetes management if applicable. Regular monitoring for both ischemic and bleeding events is essential, and the antiplatelet strategy should be reassessed if the patient develops new thrombotic events or worsening vascular disease. Alternative antiplatelet therapies, such as ticagrelor or prasugrel, could be considered if additional antiplatelet therapy is needed, but these may also cause bleeding 1.

Key points to consider in this patient's management include:

• Continuing aspirin 81mg daily and rosuvastatin for secondary prevention
• Avoiding the addition of Xarelto 2.5mg daily due to increased bleeding risk
• Focusing on other cardiovascular risk factors like smoking cessation and blood pressure control
• Regular monitoring for both ischemic and bleeding events
• Reassessing the antiplatelet strategy if the patient develops new thrombotic events or worsening vascular disease 1.

From the FDA Drug Label

Rivaroxaban tablets may cause serious side effects, including: Increased risk of bleeding. Rivaroxaban tablets can cause bleeding which can be serious and may lead to death. You may have a higher risk of bleeding if you take rivaroxaban tablets and have certain other medical problems You may have a higher risk of bleeding if you take rivaroxaban tablets and take other medicines that increase your risk of bleeding, including: aspirin or aspirin containing products Reducing the risk of serious heart problems, heart attack and stroke in coronary artery disease: Take rivaroxaban tablets 2.5 mg 2 times a day with or without food.

The patient is already taking aspirin 81mg qd and experiencing easy bruising with Plavix. The use of Xarelto 2.5mg daily may increase the risk of bleeding due to the concomitant use of aspirin. There is no clear benefit of switching to Xarelto in this case, and it may not be better for easy bleeding due to the increased risk of bleeding associated with concomitant aspirin use 2, 2, 2.

From the Research

Patient Profile and Current Medication

• The patient is a 74-year-old male with vasculopathy, a smoker, and has coronary calcifications.
• He has a history of angioplasty in the lower extremity (LE) and severe narrowing of aorticiliac arteries and the superior mesenteric artery (SMA).
• He is currently on rosuvastatin and aspirin 81mg daily.
• He experiences easy bruising as a side effect of Plavix.

Alternative Medication Options

• The patient is considering alternative medications to manage his condition, including Xarelto 2.5mg daily.
• Xarelto (rivaroxaban) is a direct factor Xa inhibitor that has been shown to be effective in reducing the risk of major cardiac and ischemic limb events in patients with peripheral artery disease (PAD) 3.
• However, the patient is concerned about the risk of bleeding with Xarelto, given his history of easy bruising with Plavix.

Bleeding Risk with Rivaroxaban

• Studies have shown that rivaroxaban increases the risk of major bleeding compared to aspirin alone 3, 4.
• However, the risk of bleeding with rivaroxaban may be similar to that of oral anticoagulants such as warfarin in elderly patients 5.
• The VOYAGER PAD trial found that rivaroxaban plus aspirin reduced the risk of adverse cardiovascular and limb events, but increased the risk of major bleeding compared to aspirin alone 3.
• The GEMINI-ACS-1 trial is currently investigating the safety of rivaroxaban plus a P2Y12 inhibitor (clopidogrel or ticagrelor) compared to dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) in patients with acute coronary syndrome 4.

Management of Easy Bruising

• Easy bruising can be a challenging condition to manage, and a detailed history and physical examination are essential to identify underlying causes 6.
• In some cases, referral to a specialist such as a hematologist may be necessary to rule out underlying bleeding disorders.
• The patient's easy bruising with Plavix may be a concern with Xarelto as well, and close monitoring of bleeding risk may be necessary.