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      Use of rivaroxaban in an elderly patient with intermediate-low early mortality risk due to pulmonary embolism: a case report

      case-report

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          Abstract

          Introduction

          Pulmonary embolism remains one of the leading causes of cardiovascular mortality. The standard treatment for pulmonary embolism is anticoagulant therapy using low molecular weight heparin, fondaparinux and a vitamin K antagonist, but a recent clinical trial showed that rivaroxaban, an oral factor Xa inhibitor, was as effective as standard therapy for the initial and long-term treatment of pulmonary embolism and had less bleeding complications.

          Case presentation

          The present report describes the case of an 80-year-old white man with an intermediate to low early mortality risk of pulmonary embolism. He was successfully treated with rivaroxaban (administered orally as monotherapy), demonstrating rapid benefit without any adverse events.

          Conclusion

          Rivaroxaban, particularly in the acute phase of pulmonary embolism, may be considered an effective and safe therapeutic choice even in elderly patients, a population less represented in clinical trials.

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          Most cited references6

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          The epidemiology of venous thromboembolism in the community.

          John Heit (2008)
          Article 0 comments Cited 138 times – based on 0 reviews     Review now
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            Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy.

            Andrew P. Stein, Nancy Henry (1995)
            The purpose of this investigation is to estimate the prevalence of acute pulmonary embolism (PE) in a general hospital, its frequency among patients who died, and the ability of physicians to diagnose PE antemortem. The prevalence of acute PE among 51,645 patients hospitalized over a 21-month period was assessed in 1 of the 6 clinical centers (Henry Ford Hospital) that participated in the collaborative study, prospective investigation of pulmonary embolism diagnosis (PIOPED). The diagnosis of PE was made by pulmonary angiography, or in those who did not undergo pulmonary angiography because they declined or were ineligible for randomization to angiography in PIOPED, the diagnosis was based on the ventilation/perfusion (V/Q) lung scan. Based on data in PIOPED, PE was considered to be present in 87% of patients with high probability V/Q scam interpretations, 30% with intermediate probability interpretations, 14% with low probability interpretations, and 4% with nearly normal V/Q scans. The estimated prevalence of acute PE in hospitalized patients was 526 of 51,645 (1.0%; 95% confidence interval [CI], 0.9 to 1.1%). Based on extrapolated data from autopsy, PE was estimated to have caused or contributed to death in 122 of 51,645 (0.2%; 95% CI, 0.19 to 0.29%). Pulmonary embolism was observed at autopsy in 59 of 404 (14.6%; 95% CI, 11.3 to 18.4%). Among patients with PE at autopsy, the PE caused or contributed to death in 22 of 59 (37.3%; 95% CI, 25.0 to 50.9%) and PE was incidental in 37 of 59 (62.7%; 95% CI, 49.1 to 75.0%). Among patients at autopsy who died from PE, the diagnosis was unsuspected in 14 of 20 (70.0%; 95% CI, 45.7 to 88.1%). Most of these patients had advanced associated disease. In these patients, death from PE occurred within 2.5 h in 13 of 14 (92.9%; 95% CI, 66.1 to 99.8%). Pulmonary embolism is common in a general hospital. The prevalence of PE at autopsy has not changed over 3 decades. The frequency of unsuspected PE in patients at autopsy has not diminished. Even among patients who die from PE, the PE is usually unsuspected. Such patients, however, typically have advanced disease. Among moribund patients, incidental PE is rarely diagnosed. Patients who suffer sudden unexplained catastrophic events in the hospital are a group in whom the diagnosis might be suspected more frequently if physicians maintain a high index of suspicion.
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              Dose-escalation study of the pharmacokinetics and pharmacodynamics of rivaroxaban in healthy elderly subjects.

              Jack Roth, Dagmar Kubitza, Wolfgang Mueck … (2008)
              The aim of this study was to investigate the pharmacokinetics and pharmacodynamics of rivaroxaban--a novel, oral, direct Factor Xa (FXa) inhibitor--in healthy elderly subjects. In this single-centre, single-blind, placebo-controlled, parallel-group, dose-escalation study, 48 subjects (aged 60-76 years) were randomized to receive a single oral dose of 30, 40 or 50 mg of rivaroxaban or placebo. Rivaroxaban was absorbed rapidly, reaching peak plasma concentration (C(max)) 4 h after dosing in all groups. Bioavailability, in terms of the area under the plasma concentration-time curve (AUC) and C(max), increased slightly (less than dose proportionally) after administration of rivaroxaban 40 mg compared with 30 mg, but was not increased further with rivaroxaban 50 mg. Rivaroxaban pharmacodynamic effects (inhibition of FXa activity and prolongation of prothrombin time, activated partial thromboplastin time and HepTest) all showed a similar pattern, with maximum inhibition of FXa activity increasing from 68% after rivaroxaban 30 mg to 75% after 40 mg and no further increase with the 50 mg dose. Most adverse events were mild; observed rates were less than placebo for the 30 and 40 mg dose groups, and similar to placebo for 50 mg. No differences were found between male and female subjects. Effects of rivaroxaban doses above 50 mg were not investigated in this study. Each single dose of rivaroxaban was well tolerated, with predictable pharmacokinetics and pharmacodynamics at doses up to 40 mg, and provided effective anticoagulation in healthy elderly subjects. Adverse events were somewhat elevated in the 50 mg group, but given the small sample size, no specific conclusions can be drawn about this dosing level.
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                Author and article information

                Contributors
                Maurizio Menichetti: +39 0544 285101 , menicmauri@gmail.com
                Journal
                Journal ID (nlm-ta): J Med Case Rep
                Journal ID (iso-abbrev): J Med Case Rep
                Title: Journal of Medical Case Reports
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1752-1947
                Publication date (Electronic): 26 November 2015
                Publication date PMC-release: 26 November 2015
                Publication date Collection: 2015
                Volume: 9
                Electronic Location Identifier: 274
                Affiliations
                UO PS/MURG OC S. Maria delle Croci, Viale Randi 5, 48121 Ravenna, Italy
                Article
                Publisher ID: 758
                DOI: 10.1186/s13256-015-0758-6
                PMC ID: 4660829
                PubMed ID: 26607201
                SO-VID: 25cbb0cd-205a-463a-bd24-912e93437796
                Copyright © © Menichetti et al. 2015
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 12 June 2015
                Date accepted : 5 November 2015
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2015

                ScienceOpen disciplines: Medicine
                Keywords: anticoagulant,case report,elderly,mortality risk,pulmonary embolism,rivaroxaban
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: anticoagulant, case report, elderly, mortality risk, pulmonary embolism, rivaroxaban

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