Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice.
- Author:
David J SEIFFGE
1
;
Christopher TRAENKA
;
Alexandros A POLYMERIS
;
Sebastian THILEMANN
;
Benjamin WAGNER
;
Lisa HERT
;
Mandy D MÜLLER
;
Henrik GENSICKE
;
Nils PETERS
;
Christian H NICKEL
;
Christoph STIPPICH
;
Raoul SUTTER
;
Stephan MARSCH
;
Urs FISCH
;
Raphael GUZMAN
;
Gian Marco DE MARCHIS
;
Philippe A LYRER
;
Leo H BONATI
;
Dimitrios A TSAKIRIS
;
Stefan T ENGELTER
Author Information
- Publication Type:Original Article
- Keywords: Rivaroxaban; Stroke; Plasma levels; Thrombolysis
- MeSH: Arteries; Hemorrhage; Humans; National Institutes of Health (U.S.); Plasma*; Rivaroxaban*; Stroke*
- From:Journal of Stroke 2017;19(3):347-355
- CountryRepublic of Korea
- Language:English
- Abstract: BACKGROUND AND PURPOSE: Standard operating procedures (SOP) incorporating plasma levels of rivaroxaban might be helpful in selecting patients with acute ischemic stroke taking rivaroxaban suitable for IVthrombolysis (IVT) or endovascular treatment (EVT). METHODS: This was a single-center explorative analysis using data from the Novel-Oral-Anticoagulants-in-Stroke-Patients-registry (clinicaltrials.gov:NCT02353585) including acute stroke patients taking rivaroxaban (September 2012 to November 2016). The SOP included recommendation, consideration, and avoidance of IVT if rivaroxaban plasma levels were < 20 ng/mL, 20‒100 ng/mL, and >100 ng/mL, respectively, measured with a calibrated anti-factor Xa assay. Patients with intracranial artery occlusion were recommended IVT+EVT or EVT alone if plasma levels were ≤100 ng/mL or >100 ng/mL, respectively. We evaluated the frequency of IVT/EVT, door-to-needle-time (DNT), and symptomatic intracranial or major extracranial hemorrhage. RESULTS: Among 114 acute stroke patients taking rivaroxaban, 68 were otherwise eligible for IVT/EVT of whom 63 had plasma levels measured (median age 81 years, median baseline National Institutes of Health Stroke Scale 6). Median rivaroxaban plasma level was 96 ng/mL (inter quartile range [IQR] 18‒259 ng/mL) and time since last intake 11 hours (IQR 4.5‒18.5 hours). Twenty-two patients (35%) received IVT/EVT (IVT n=15, IVT+EVT n=3, EVT n=4) based on SOP. Median DNT was 37 (IQR 30‒60) minutes. None of the 31 patients with plasma levels >100 ng/mL received IVT. Among 14 patients with plasma levels ≤100 ng/mL, the main reason to withhold IVT was minor stroke (n=10). No symptomatic intracranial or major extracranial bleeding occurred after treatment. CONCLUSIONS: Determination of rivaroxaban plasma levels enabled IVT or EVT in one-third of patients taking rivaroxaban who would otherwise be ineligible for acute treatment. The absence of major bleeding in our pilot series justifies future studies of this approach.
