Massive intoxication with rivaroxaban, phenprocoumon, and diclofenac

Abstract

Rationale:Oral anticoagulants and painkillers, some with an additional effect on the coagulation system, are widely used and are therefore prone to abuse and (intentional) overdose. We report the case of a patient with a massive mixed anticoagulant intoxication.Patient concerns:The patient had ingested 1960 mg rivaroxaban, 31.5 mg phenprocoumon, 1425 mg diclofenac, and 21,000 mg metamizole in suicidal intention.Diagnoses:Massive mixed anticoagulant overdose.Interventions:The patient was closely monitored. The phenprocoumon overdose was treated by the administration of vitamin K and PCC.Outcomes:Despite the massive inhibition of the coagulation system, the patient did not experience bleeding apart from a slight gross hematuria.Lessons:Despite the ingestion of a massive amount of rivaroxaban, the plasma levels were not as high as feared, due to the ceiling effect of rivaroxaban absorption. Elimination occurred according to the half-life of rivaroxaban and was not unduly prolonged by the ingested quantity.

Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum

“…Cases involving apixaban and dabigatran have likewise been conservatively managed with success . While blood products and idarucizumab have also been administered safely in some overdose cases, their impact on clinical outcomes is unclear …”

Conservative management of massive rivaroxaban overdose: A case report and literature review

“…We conducted a literature search to identify similar cases, and the characteristics of the patients, along with the treatment, are shown in Table 1 . 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 …”

“…Here, we reported a case of rivaroxaban overdose that had a favorable outcome with conservative management and did not require the administration of any fresh frozen plasma, blood products, or prothrombin complex concentrate (PCC). We conducted a literature search to identify similar cases, and the characteristics of the patients, along with the treatment, are shown in Table 1 7‐18 …”

“…We conducted a literature search to identify similar cases, and the characteristics of the patients, along with the treatment, are shown in Table 1. [7][8][9][10][11][12][13][14][15][16][17][18] The use of rivaroxaban in anticoagulant treatment has increased, and its administration is expected to rise significantly. 5 One of the problems with rivaroxaban overdose is how to measure and monitor its impacts on the coagulation system.…”

Intentional overdose of rivaroxaban and alcohol: A case report

“…10 There are reports of managing patients after rivaroxaban overdose with activated charcoal, tranexamic acid, prothrombin complex concentrates, vitamin K, fresh frozen plasma, and desmopressin. [11][12][13] Activated charcoal in healthy volunteers significantly reduces gut absorption of rivaroxaban, even if given up to 8 hours after ingestion 14 ; therefore, its use is recommended in patients after rivaroxaban overdose (grade 2C recommendation). Andexanet alfa is a new reversal agent for factor Xa inhibitors, such as rivaroxaban and apixaban, that was approved by the FDA in May 2018 in patients with life-threatening or uncontrolled bleeding.…”