What is the management for an elderly patient on Xarelto (rivaroxaban) after a fall?

Management of Elderly Patient on Xarelto After a Fall

Elderly patients on rivaroxaban (Xarelto) who fall require immediate comprehensive trauma evaluation with a lower threshold for activation of trauma protocols, screening for anticoagulant medications, assessment for occult bleeding injuries (particularly intracranial hemorrhage), and consideration of anticoagulation reversal only in cases of life-threatening bleeding with dosable plasma levels. 1

Immediate Assessment and Triage

Lower the threshold for trauma activation in elderly patients on anticoagulants. The 2023 WSES guidelines specifically recommend trauma protocol activation at heart rate ≥90 bpm and systolic blood pressure <110 mmHg in geriatric patients, recognizing that anticoagulation (including rivaroxaban) puts these patients at high risk for significant bleeding events even after minor trauma. 1

Critical Initial Steps

• Screen for anticoagulant use immediately upon admission as part of the poly-pharmacologic profile assessment, specifically identifying rivaroxaban, other DOACs, warfarin, and antiplatelet agents. 1

• Maintain high suspicion for occult injuries even with seemingly minor mechanisms, as traumatic injuries in geriatric patients may present without classic signs or symptoms. 1

• Obtain detailed fall history including location and cause of fall, time spent on floor/ground, loss of consciousness, near-syncope, difficulty with gait/balance, and previous falls. 1

Bleeding Risk Assessment

Patients on rivaroxaban do not have increased rates of bleeding injury from falls compared to non-anticoagulated patients (12.8% vs 12.7%), but they have significantly higher mortality when bleeding does occur (21.5% vs 6.9%). 2

High-Risk Injuries Requiring Extensive Workup

• Blunt head trauma - CT head imaging should be obtained liberally given the high risk of intracranial hemorrhage in anticoagulated patients. 1

• Spinal fractures - Falls are the main cause of trauma in geriatric patients (75% of cases), and cervical spine fractures are more common in elderly fallers. 1

• Rib fractures and chest injuries - Can exacerbate preexisting cardiopulmonary disease and increase risk of pneumonia and respiratory failure. 1

• Hip and extremity fractures - 6% of ground-level falls result in fractures, with 10-30% having polytrauma. 1

Laboratory and Coagulation Assessment

Early assessment of both laboratory coagulation tests and direct measurements of DOAC levels is crucial in trauma patients receiving rivaroxaban. 1

Specific Testing for Rivaroxaban

• Chromogenic anti-FXa assay calibrated with rivaroxaban is the preferred quantitative test. 1

• PT is more affected than aPTT by rivaroxaban (direct FXa inhibitor), though a normal PT/aPTT cannot rule out DOAC effect. 1

• Universal LMWH-calibrated anti-Xa activity assay may determine rivaroxaban concentrations and correctly predict relevant drug levels. 1

• Viscoelastic coagulation tests (ROTEM or Clot-Pro) may be helpful, as rivaroxaban progressively prolongs clotting time. 1

Anticoagulation Reversal Decision-Making

Administer reversal agents ONLY in critically ill patients with dosable plasma DOAC levels presenting with hemorrhagic shock not responding to resuscitation or life-threatening uncontrolled bleeding. 1

Reversal Protocol for Rivaroxaban

• Andexanet alfa is the recommended reversal agent for rivaroxaban-associated life-threatening bleeding:

  • Low dose: 400 mg IV bolus over 15 minutes, followed by 480 mg infusion over 2 hours
  • High dose: 800 mg IV bolus over 30 minutes, followed by 960 mg infusion over 2 hours
  • Dose selection based on last rivaroxaban dose and timing 1

• If andexanet alfa is unavailable, administer 2000 units of four-factor prothrombin complex concentrates (PCC) or 25-50 U/kg. 1

• Co-administer tranexamic acid (15 mg/kg or 1 g) independent of reversal strategy in trauma patients. 1

Important Caveats on Reversal

• Do NOT routinely reverse anticoagulation in stable patients without active bleeding, as the thromboembolic risk must be weighed against bleeding risk. 1

• Rivaroxaban is NOT dialyzable due to high plasma protein binding. 3

• Protamine sulfate and vitamin K do NOT affect rivaroxaban anticoagulant activity. 3

• Monitoring anticoagulation effect using PT, INR, aPTT, or anti-FXa activity is NOT recommended for clinical decision-making. 3

Renal Function Considerations

Rivaroxaban depends on renal function for clearance, resulting in higher blood levels and longer half-lives in patients with renal dysfunction. 1

• Assess creatinine clearance as patients with renal dysfunction may benefit from desmopressin acetate or cryoprecipitate for uremia-associated platelet dysfunction. 1

• Consider hemodialysis optimization in patients with significant renal impairment, though rivaroxaban itself is not dialyzable. 1

• Terminal elimination half-life is 5-9 hours in healthy subjects aged 20-45 years, but may be prolonged in elderly patients with renal impairment. 3

Comprehensive Fall Evaluation

Beyond trauma assessment, evaluate the underlying cause of the fall:

Key Historical Elements

• Medication assessment with special attention to vasodilators, diuretics, antipsychotics, sedative/hypnotics, and rivaroxaban itself. 1

• Orthostatic blood pressure assessment to identify syncope or near-syncope. 1

• Comorbidities including dementia, Parkinson's, stroke, diabetes, hip fracture, and depression. 1

• Visual or neurological impairments such as peripheral neuropathies. 1

Diagnostic Testing Threshold

• Maintain low threshold for EKG, complete blood count, electrolyte panel, and appropriate imaging even in seemingly straightforward falls. 1

• Complete head-to-toe evaluation for ALL patients, including those with seemingly isolated injuries. 1

Recurrent Fall Risk

Among elderly patients hospitalized for a fall, 4.7% will be hospitalized for a recurrent fall within 6 months, with a median time to repeat fall of 57 days. 2

Disposition Planning

• Safety assessment prior to discharge including gait evaluation and "get up and go test" - patients unable to rise from bed, turn, and steadily ambulate should be reassessed. 1

• Admission should be considered if patient safety cannot be ensured at home. 1

• All admitted patients should be evaluated by physical therapy and occupational therapy. 1

• Expedited outpatient follow-up with home safety assessments is recommended for discharged patients. 1

Anticoagulation Continuation Decision

The decision to restart rivaroxaban after a fall should NOT be based primarily on fall risk alone. Research demonstrates that older adults would need to fall over 45 times per year for rivaroxaban's quality-adjusted life-years to be lower than aspirin. 4

Factors Supporting Continuation

• Stroke prevention benefit typically outweighs bleeding risk even in patients at high risk of falls. 4

• High risk of falls is associated with clinically relevant nonmajor bleeding (SHR 1.74) but NOT with major bleeding (SHR 1.24) in elderly patients on anticoagulation for VTE. 5

Factors Against Continuation

• Active pathological hemorrhage - discontinue rivaroxaban immediately. 3

• Recurrent falls with inability to participate in rehabilitation despite adequate interventions may indicate end-of-life process rather than recovery trajectory. 6

• Subdural hematoma or intracranial hemorrhage - timing of anticoagulation restart requires multidisciplinary discussion. 7

Common Pitfalls to Avoid

• Do not assume all elderly fallers on anticoagulation need reversal - only those with life-threatening bleeding and dosable drug levels require reversal agents. 1

• Do not delay CT head imaging in anticoagulated elderly patients with head trauma, even with normal neurological examination. 1

• Do not use fall risk as the primary reason to withhold anticoagulation - the stroke prevention benefit typically outweighs bleeding risk. 4

• Do not restart anticoagulation without addressing modifiable fall risk factors including polypharmacy, orthostatic hypotension, and environmental hazards. 1

• Do not forget VTE prophylaxis - LMWH or UFH should be administered as soon as possible in high and moderate-risk elderly trauma patients according to renal function, weight, and bleeding risk. 1