What is the treatment for a patient taking Xarelto (rivaroxaban) who presents with bloody stools?

Management of Bloody Stools in a Patient Taking Rivaroxaban (Xarelto)

For a patient taking Xarelto who presents with bloody stools, immediately interrupt the anticoagulant therapy and seek medical attention for evaluation and management of the gastrointestinal bleeding. 1

Initial Assessment and Management

• Immediately discontinue rivaroxaban (Xarelto) at presentation with bloody stools, as this represents lower gastrointestinal bleeding (LGIB) that requires prompt evaluation 1
• Assess the severity of bleeding through clinical evaluation, looking for signs of hemodynamic instability (tachycardia, hypotension), volume depletion, and the amount of blood in the stool 1
• Evaluate for colitis symptoms that may accompany bloody stools, including watery diarrhea, cramping, urgency, abdominal pain, mucus in stool, fever, and nocturnal bowel movements 1
• Consider other causes of gastrointestinal bleeding, including peptic ulcer disease, malignancy, diverticulosis, angiodysplasia, hemorrhoids, and ischemia 1

Diagnostic Workup

• For moderate to severe bleeding (Grade 2 or higher with >4 bowel movements per day above baseline and/or colitis symptoms), obtain abdominal/pelvic CT with contrast 1
• Consider gastrointestinal consultation for colonoscopy or flexible sigmoidoscopy with biopsy to determine the cause and location of bleeding 1
• Obtain laboratory tests to assess hemoglobin levels, coagulation parameters, and renal function 1
• For patients on rivaroxaban, anti-factor Xa assays with specific calibrators can be used to measure plasma drug concentration if available 1

Acute Management of Bleeding

• For severe bleeding, implement general resuscitation measures including:

  • Fluid replacement and correction of anemia with red blood cell transfusion if needed 1
  • Consider prothrombin complex concentrate (PCC, 50 IU/kg of 4-factor concentrate) which can reverse the anticoagulant effect of rivaroxaban 1
  • For life-threatening hemorrhage, consider andexanet alfa, a specific reversal agent for factor Xa inhibitors 1
  • Tranexamic acid may be reasonable to use, although evidence for its effectiveness with DOACs is limited 1

• Fresh frozen plasma is not effective in reversing the anticoagulant effect of rivaroxaban and should only be used for documented dilutional coagulopathy 1

Resuming Anticoagulation

• After the bleeding has been controlled, consider restarting rivaroxaban at a maximum of 7 days after the hemorrhage has resolved 1
• The decision to restart should balance the risk of rebleeding versus the risk of thrombosis without anticoagulation 1
• For patients at high risk of rebleeding, consider switching to warfarin which allows more effective and rapid reversal of anticoagulation if needed 1
• Be aware that unlike warfarin, which takes days to achieve therapeutic anticoagulation, rivaroxaban restores full anticoagulant effect within 3 hours of taking a dose 1

Important Considerations and Caveats

• Rivaroxaban has been associated with an increased risk of lower gastrointestinal bleeding, particularly in elderly patients 1
• Rivaroxaban has a half-life of 7-11 hours in patients with normal renal function, but this can be prolonged with renal impairment 1
• Avoid NSAIDs while taking rivaroxaban as they increase bleeding risk 2
• Acetaminophen is generally considered a safe pain reliever option for patients on rivaroxaban 2
• When restarting anticoagulation, consult with the clinician who initially prescribed rivaroxaban to ensure appropriate management of the underlying condition requiring anticoagulation 1