What is the treatment for an elderly patient on rivaroxaban (direct oral anticoagulant) presenting with acute stroke symptoms?

Management of Acute Stroke in Elderly Patients on Rivaroxaban

For elderly patients on rivaroxaban presenting with acute stroke symptoms, the recommended treatment is administration of andexanet alfa for life-threatening bleeding or reversal of anticoagulation prior to urgent procedures, with dosing based on the last dose of rivaroxaban and timing of administration. 1

Initial Assessment and Stabilization

• Immediately assess:
  • Time since last rivaroxaban dose
  • Severity of neurological deficits (using NIH Stroke Scale)
  • Type of stroke (ischemic vs. hemorrhagic) via urgent brain imaging (CT/MRI)
  • Laboratory tests: complete blood count, coagulation tests, renal function
  • Direct measurement of rivaroxaban levels if available (results can be obtained within ~34 minutes) 2

Management Algorithm for Acute Stroke on Rivaroxaban

For Hemorrhagic Stroke:

1. Reversal of Anticoagulation:

   • First-line therapy: Administer andexanet alfa as an intravenous bolus followed by continuous infusion 1:
     • Low dose: 400 mg IV bolus over 15 min followed by 480 mg infusion over 2 hours
     • High dose: 800 mg IV bolus over 30 min followed by 960 mg infusion over 2 hours
   • Alternative if andexanet alfa unavailable: Administer 2000 units of four-factor prothrombin complex concentrate (PCC) 1

2. Supportive care:

   • Blood pressure management
   • Neurosurgical consultation for large hematomas or cerebellar hemorrhages
   • Prevention of secondary injury

For Ischemic Stroke:

1. Thrombolysis considerations:

   • Standard thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) is generally contraindicated in patients on rivaroxaban 3, 4, 5
   • Thrombolysis may be considered only if:
     • Rivaroxaban levels are low or undetectable
     • Last dose was >48 hours ago
     • Normal coagulation parameters
     • Benefits clearly outweigh risks

2. Mechanical thrombectomy:

   • Consider for large vessel occlusions regardless of rivaroxaban status
   • May be the preferred reperfusion strategy for patients on rivaroxaban

Monitoring and Follow-up

• Frequent neurological assessments
• Serial brain imaging to monitor for hemorrhagic transformation or hematoma expansion
• Renal function monitoring (rivaroxaban is partially eliminated via kidneys) 6

Special Considerations

• Elderly patients have increased bleeding risk and often have reduced renal function, requiring careful assessment 6
• Renal function is critical for rivaroxaban dosing and clearance; patients with CrCl <15 mL/min should not receive rivaroxaban 6
• Drug interactions can affect rivaroxaban levels (e.g., azole antimycotics, HIV protease inhibitors) 1, 6

Resumption of Anticoagulation

• For ischemic stroke: Consider restarting rivaroxaban after 3-14 days based on infarct size and bleeding risk 6
• For hemorrhagic stroke: Decision to restart anticoagulation should involve multidisciplinary assessment of risks and benefits, typically delayed by at least 4-8 weeks 1

Common Pitfalls to Avoid

1. Delaying reversal in hemorrhagic stroke while waiting for laboratory confirmation
2. Administering thrombolytics without confirming rivaroxaban activity level
3. Failing to consider drug interactions that may increase rivaroxaban levels
4. Abrupt discontinuation of rivaroxaban without transition to alternative anticoagulation 6
5. Overlooking renal function when planning treatment and follow-up

Rapid assessment, appropriate reversal strategies, and careful consideration of the risks and benefits of interventions are essential for optimizing outcomes in elderly patients with acute stroke who are on rivaroxaban therapy.