What should be done if a patient taking Xarelto (rivaroxaban) falls?

Management of Patients on Rivaroxaban After a Fall

In patients taking Xarelto (rivaroxaban) who experience a fall, immediate assessment for bleeding complications and potential reversal of anticoagulation is required, with administration of andexanet alfa for life-threatening bleeding or bleeding in critical organs. 1

Initial Assessment

When a patient on rivaroxaban falls, perform an immediate evaluation for:

• Signs of external bleeding
• Neurological deficits suggesting intracranial hemorrhage
• Pain suggesting internal bleeding (abdominal, retroperitoneal, intramuscular)
• Vital signs for hemodynamic instability
• Mental status changes

Management Algorithm

Step 1: Determine Bleeding Severity

Life-threatening or critical organ bleeding:

• Intracranial hemorrhage
• Bleeding in closed space (intraspinal, intraocular, pericardial, pulmonary, retroperitoneal)
• Hemodynamically unstable bleeding
• Persistent major bleeding despite local measures 1

Non-life-threatening bleeding:

• Minor external bleeding
• Stable patient without evidence of critical organ involvement

Step 2: Laboratory Assessment

Obtain urgent:

• Complete blood count
• Renal function (creatinine clearance)
• Anti-Factor Xa activity if available (though don't delay treatment in emergency) 1

Step 3: Reversal Strategy Based on Bleeding Severity

For life-threatening or critical organ bleeding:

1. Administer andexanet alfa (preferred reversal agent for rivaroxaban) 1

   • Low dose: 400 mg IV bolus followed by 4 mg/min infusion for up to 120 minutes (480 mg total)
   • High dose: 800 mg IV bolus followed by 8 mg/min infusion for up to 120 minutes (960 mg total)

2. If andexanet alfa unavailable:

   • Administer prothrombin complex concentrate (PCC) 25-50 U/kg 1

3. Consider activated charcoal if rivaroxaban was ingested within 2-4 hours 1

For non-life-threatening bleeding:

• Supportive care
• Local hemostatic measures
• Consider delaying next rivaroxaban dose
• Monitor closely for bleeding progression

Step 4: Post-Fall Monitoring

• Neurological checks every 1-2 hours for 24 hours (if head trauma)
• Serial hemoglobin measurements
• Monitor for delayed bleeding complications
• Assess for injuries requiring surgical intervention

Special Considerations

1. Timing of last dose:

   • If last dose was >24 hours ago in patients with normal renal function, reversal may not be necessary as drug effect will be minimal 1
   • For impaired renal function (CrCl <30 mL/min), drug effect may persist longer 2

2. Restarting anticoagulation:

   • After minor falls without significant bleeding: Resume when hemostasis is adequate, typically within 24 hours 3
   • After major bleeding: Delay resumption for at least 24-72 hours and reassess thrombotic vs. bleeding risk 1

3. Fall prevention:

   • Implement fall prevention strategies for all patients on rivaroxaban
   • Consider balance training, home safety evaluation, and vision assessment

Pitfalls to Avoid

1. Delaying reversal in critical bleeding situations while waiting for laboratory results
2. Unnecessary reversal for minor falls without evidence of significant bleeding
3. Premature resumption of anticoagulation before adequate hemostasis is achieved
4. Failure to monitor for delayed bleeding complications, especially with head trauma
5. Not considering renal function when assessing drug clearance and timing of last dose 2

By following this structured approach, clinicians can effectively manage patients on rivaroxaban who experience falls, minimizing both bleeding complications and thrombotic risks.