Presentation Details
| Anticoagulation Stewardship: Appropriate use of Apixaban and Rivaroxaban Factor Xa levels in the Emergency Department Firas Quran, Sara Zochert, Michael Gulseth, Alicia Martin. Sanford USD Medical Center and Hospital, Sioux Falls, SD, USA |
Abstract
Background: The use of Factor Xa (FXa) inhibitors has increased substantially since their implementation in recent guidelines. A couple benefits of FXa inhibitors include the ease of dosing and, most notably, lack of routine monitoring. Some facilities have the capability to obtain apixaban and rivaroxaban anti-Xa drug levels, however due to the lack of FDA approval and lack of evidence surrounding the support of monitoring their plasma drug concentration, utilization of FXa drug levels in direct patient care remains questionable. A previous study investigated plasma concentrations of rivaroxaban in relation to patients presenting with hemorrhages or thrombosis. Patients presenting with out-of-range concentrations had more bleeding or thrombus when compared to patients with expected concentrations. Patients with bleeding were found to have concentrations beyond the ninety-five percentiles, however patients with thrombosis were more likely to have concentrations below the fifth percentile. Additional trials have shown potential benefits for monitoring FXa drug concentrations in emergent situations. Potential indications for lab monitoring include: trauma, urgent surgery/invasive procedures, major bleeding, overdose, acute thrombosis, renal failure, liver failure, and potential drug–drug interactions. At our facility, we have a guideline that utilizes FXa drug levels to aid in transitioning from a FXa inhibitor to heparin intravenous infusion. Since there is no official therapeutic range for any FXa inhibitor, assessing anti-Xa level can be challenging. In our facility, we noticed potential overutilization of rivaroxaban and apixaban calibrated anti-Xa drug levels. This study will act as an anticoagulation stewardship review to validate appropriate use of these levels. Objectives: The main objective of this study is to standardize a list of appropriate indications of when to order non-FDA approved apixaban and rivaroxaban calibrated anti-Xa levels in the emergency department. Methods: This is a retrospective cohort study of adults who had an apixaban or rivaroxaban anti-Xa level obtained in the emergency department between July 1, 2022, to June 30, 2023. Patients were excluded from this research if they were under the age of 18 or pregnant. Secondary outcomes including baseline characteristics, indication for the apixaban or rivaroxaban anti-Xa level (adherence/compliance, acute thrombosis, major bleeding, urgent invasive procedures/surgeries, trauma, overdose, renal failure, liver failure, and drug-drug interactions), financial impact of lab ordering, and patient outcomes (if lab result led to a change in therapy) will be analyzed. Results/Conclusion: Research is still in progress.
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No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.