PO01 - Successful Treatment of Subarachnoid Hemorrhage using Prothrombin Complex Concentrate in Patient Taking Routine Oral Rivaroxaban

Background: The advent of direct oral anticoagulants (DOACs) such as Rivaroxaban has been associated with better patient comfort and adherence. However, because of easy administration, this drug is often used to treat asymptomatic patients without clear indications for anticoagulation. This leads to increased adverse effects such as bleeding events.

Aims: This is a case report which demonstrates the treatment of subarachnoid hemorrhage patient taking routine oral Rivaroxaban in a developing country where specific antidote is not available.

Methods: A 56-year-old man came with worsening headache after motorbike accident. He did not wear a protective helmet. He was diagnosed with hypercoagulation and had been taking daily Rivaroxaban for the last 3 months. Brain CT-scan showed subarachnoid hemorrhage and right parietal subgaleal hematoma. Andexanet alfa is not available in Indonesia, therefore 2,000 units of intravenous prothrombin complex concentrate (PCC) was administered. The headache resolved, activated partial thromboplastin time was reduced from 1.3 times control to 0.9 times control, and Anti Xa was restored to normal. After thorough reassessment, this patient did not require anticoagulation and the drug was discontinued. The patient was discharged without significant morbidity.

Results: This patient experienced subarachnoid hemorrhage after a motorbike accident. Bleeding in the central nervous system is considered life-threatening and should be treated promptly. In patients taking Rivaroxaban, specific antidote Andexanet alfa should be given. In the absence of the antidote, PCC serves as a feasible alternative as reversal agent to counter the effect of Rivaroxaban. To prevent such incidents in the future, consideration should be given to whether specific indications are present every time an oral anticoagulant is given.

Conclusion(s): Prothrombin complex concentrate can be used as alternative to Andexanet alfa as treatment for life-threatening bleeding events in patients taking DOAC Rivaroxaban.