Probable Rivaroxaban-Induced Full Body Rash: A Case Report

Design

Case report

Case Presentation

A 79-year-old African American female taking rivaroxaban 20 mg PO at bedtime for atrial fibrillation following a stroke developed a full body rash, leading to hospitalization and transfer to acute rehabilitation for continued care. Other medications include metoprolol tartrate, atorvastatin, insulin detemir, docusate sodium, acetaminphen, and aspirin. Patient restarted rivaroxaban 20 mg with dinner during rehabilitation.

After stepping down to a nursing home to complete rehabilitation, the patient developed pruritic rash between 7 to 9 days (exact date unspecified). Treatment with diphenhydramine PO as needed along with miconazole to the abdomen was started. However, rash persisted leading to increased dose of diphenhydramine. IV methylprednisolone led to improvement of rash and the patient was switched from rivaroxaban to apixaban 5 mg BID with no additional reactions.

Study Author Conclusions

We report one of the first cases of probable rivaroxabaninduced rash, whereas the patient tolerated apixaban. Further investigation is warranted, but prescribers should be cognizant of this potential issue when choosing a factor Xa inhibitor for anticoagulation.

Design

Case report

Case Presentation

A 67-year-old male developed rash on his arms, legs, and abdomen 2 to 3 weeks after starting apixaban. The patient had a similar reaction to rivaroxaban. IgA vasculitis was suspected which led to further investigation via biopsy, confirming the suspicion. The patient was switched to warfarin and prednisone tapering plus dapsone 50mg daily was used to treat the rash.

A 48-year-old male was started on apixaban for chronic anticoagulation due to cardiac stent placement. Five days later, palpable purpura was developed on the lower legs. The lesions spread to the abdomen and upper extremities over the next four days. Biopsy revealed symptoms similar to IgA vasculitis and the patient was treated with corticosteroids for symptomatic relief. When switching from apixaban to rivaroxaban, patient did not develop further lesions and the reaction was resolved spontaneously.

Study Author Conclusions

The first case demonstrates apixaban-induced cutaneous reaction, as well as cross-reactivity between factor Xa inhibitors. With a score of 8 on the Naranjo scale, the causality between apixaban and the patient’s cutaneous reaction was probable. Our patient had cutaneous reactions to both rivaroxaban and apixaban indicating a possible cross-reactivity between different factor Xa inhibitors with similar structures.

Design

Case report (Abstract only)

Case Presentation

A case report described a female patient with an apixaban-induced macular rash with elevated serum creatinine (2.29 mg/dL). After switching to LMWH which resolved the issue, the patient was re-challenged with apixaban, leading to recurrence of generalized pruritus and requiring treatment with diphenhydramine and prednisone. Stopping apixaban once more led to the disappearance of rash 3 days later. The patient was started on rivaroxaban which led to no further consequences.

Study Author Conclusions

Our patient’s Naranjo scale was 7 and her rash improved after cessation of apixaban. The case illustrates a hypersensitivity reaction from apixaban that did not have cross-reactivity with other FXa inhibitors. Early recognition of cutaneous adverse drug reactions from this widely used direct acting oral anticoagulant (DOAC) can avoid potential complications. Minor reactions may be managed by switching to different DOAC therapy. Whether a cross-reactivity truly exists must be explored by validated skin testing.

Design

Case report

Case Presentation

A 78-year-old male with 3-month treatment using apixaban for atrial fibrillation presented to the emergency department for development of rash on upper extremities that started one month ago. With no change in medications or other investigations showing signs of susceptible cause, patient was diagnosed to have drug-induced lichen planus possibly due to apixaban. Steroid ointment with clobetasol propionate 0.05% was initiated during the wait for a follow-up biopsy in one month which helped alleviate but not clear the rash. Several violaceous macules developed on upper extremities with biopsy revealing symptoms most likely to a lichenoid eruption. Six months later, the patient still presented with rash despite continue use of steroid ointment with new complications occurring during subsequent follow-up. 

Due to a separate issue involving the submandibular gland necessitating surgical excision, the patient stopped apixaban for 5 days prior to procedure. The rash had almost completely resolved before the procedure and reappeared when resumed post-surgery. When patient self-discontinued 2-weeks later, the patient was eventually switched to rivaroxaban which the patient reported a complete resolvement in rash. At approximately 2-month follow-up at the clinic, the patient reported complete tolerance to rivaroxaban with no rash or itching symptoms.

Study Author Conclusions

To the best of our knowledge, we report the first case of lichenoid eruption associated with apixaban. We further provide evidence of tolerance to rivaroxaban in the same patient.