How to manage a patient on Xarelto (rivaroxaban) with a duodenal ulcer, gastrointestinal bleeding, and anemia?

From the Guidelines

Management of a patient on Xarelto (rivaroxaban) with a duodenal ulcer, gastrointestinal bleeding, and anemia requires immediate discontinuation of rivaroxaban and initiation of reversal protocol with andexanet alfa, as suggested by the latest guidelines 1. The patient should be hospitalized for close monitoring and resuscitation with intravenous fluids and blood transfusions if hemoglobin levels are critically low (typically below 7-8 g/dL) or if the patient is hemodynamically unstable. Urgent endoscopy should be performed within 24 hours to identify and treat the bleeding source, which may include endoscopic interventions such as clipping, thermal coagulation, or epinephrine injection. For ulcer treatment, start high-dose proton pump inhibitor therapy (e.g., pantoprazole or esomeprazole 40 mg IV twice daily initially, then transition to oral therapy) as recommended by international consensus guidelines 1. Test for Helicobacter pylori and treat if positive with appropriate antibiotic regimen. Once bleeding is controlled and the patient is stable, reassess the indication for anticoagulation and consider alternatives with lower bleeding risk such as apixaban or a reduced dose of rivaroxaban, or potentially switching to warfarin with close INR monitoring. For patients with high thrombotic risk, anticoagulation can typically be resumed after 7-14 days following confirmed hemostasis, while those with lower risk may benefit from a longer interruption. Iron supplementation (ferrous sulfate 325 mg daily or every other day) should be initiated to treat anemia once bleeding is controlled, as recommended by recent clinical practice updates 1. Blood transfusions should be administered to a patient with a hemoglobin level of 70 g/L or less, as suggested by international guidelines 1.

Some key points to consider in the management of this patient include:

• The need for urgent endoscopy to identify and treat the bleeding source
• The use of high-dose proton pump inhibitor therapy to treat the ulcer
• The importance of testing for Helicobacter pylori and treating if positive
• The need for reassessment of anticoagulation therapy once bleeding is controlled
• The use of iron supplementation to treat anemia
• The consideration of blood transfusions for patients with critically low hemoglobin levels.

Overall, the management of a patient on Xarelto with a duodenal ulcer, gastrointestinal bleeding, and anemia requires a multidisciplinary approach and careful consideration of the latest guidelines and evidence-based recommendations.

From the FDA Drug Label

XARELTO increases the risk of bleeding and can cause serious or fatal bleeding. In deciding whether to prescribe XARELTO to patients at increased risk of bleeding, the risk of thrombotic events should be weighed against the risk of bleeding. Promptly evaluate any signs or symptoms of blood loss and consider the need for blood replacement. Discontinue XARELTO in patients with active pathological hemorrhage.

The patient should be discontinued from XARELTO due to active pathological bleeding (melena and hematemesis) and blood replacement should be considered given the patient's low Hgb (7.4). An agent to reverse the anti-factor Xa activity of rivaroxaban is available and may be considered in this scenario 2.

From the Research

Management of Patient on Xarelto with Duodenal Ulcer and Gastrointestinal Bleeding

• The patient presents with melena and hematemesis, indicating active gastrointestinal bleeding, and is on Xarelto (rivaroxaban), which can increase the risk of bleeding.
• The patient's hemoglobin level is 7.4, indicating anemia, which may require blood transfusion or other management strategies 3.
• Endoscopic therapy is recommended for patients with peptic ulcer bleeding, and the use of proton pump inhibitors (PPIs) such as pantoprazole can reduce the risk of rebleeding and improve outcomes 4, 5, 6.
• High-dose PPI therapy, such as pantoprazole infusion, has been shown to be effective in reducing rebleeding and transfusion requirements in patients with peptic ulcer bleeding 4, 6.
• Intermittent and continuous pantoprazole infusion have comparable outcomes in reducing rebleeding, and intermittent administration may have application and cost advantages 5.
• The management of severe anemia in patients who refuse blood transfusion can be challenging, and alternative strategies such as erythropoietin administration, iron supplementation, and oxygen consumption reduction may be necessary 3.

Treatment Options

• Endoscopic hemostasis to control active bleeding
• High-dose PPI therapy, such as pantoprazole infusion, to reduce the risk of rebleeding
• Blood transfusion or alternative strategies to manage anemia
• Discontinuation or reversal of Xarelto (rivaroxaban) to reduce the risk of further bleeding

Considerations

• The patient's religious beliefs or personal preferences regarding blood transfusion should be respected and alternative strategies considered 3.
• The use of PPIs and other medications should be carefully monitored and adjusted as necessary to minimize the risk of adverse effects 4, 5, 6.
• The patient's condition should be closely monitored, and urgent surgery or other interventions should be considered if necessary to control bleeding and prevent further complications 4, 5, 6.