title: Managing Subdural Bleeding Associated With Rivaroxaban: A Series of 3 Cases.
abstract: OBJECTIVE
  To report 3 cases of subdural bleeding associated with rivaroxaban managed by 3-factor prothrombin complex concentrate (PCC3).
  
  
  METHODS
  Case 1 presented with a 1-cm thick subdural hematoma (SDH) 12 hours after her last dose of rivaroxaban. Case 2 presented with a right 1-cm acute right SDH with 2 to 3 mm of midline shift 24 hours after his last dose of rivaroxaban. Case 3 presented with a 1.8-cm thick right cerebral convexity hematoma 12 hours after her last dose of rivaroxaban. All patients received 23 to 35 units/kg PCC3 with 1 to 3 units of fresh frozen plasm (FFP) and demonstrated no progression in lesions measured by repeat computed tomography (CT). Two patients were discharged to rehabilitation facilities and 1 patient ultimately died due to the location of the lesion.
  
  
  CONCLUSIONS
  Rivaroxaban has no specific antidote. Current bleeding management strategies are based on expert opinion. The risks and benefits for differing strategies are unclear, and no clinical experience has been reported to date. These cases begin to illuminate differences among choices for managing bleeding associated with Xa inhibitors.
  
  
  CONCLUSIONS
  In this case series, 25 to 35 units/kilogram PCC3 and FFP 1 to 3 units ceased rivaroxaban-associated bleeding without thrombogenic complications.
authors.affiliation: Department of Pharmacy, Texas Health Presbyterian Hospital of Dallas, Dallas, TX, USA andrewfaust@texashealth.org.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Faust
authors.affiliation: Department of Pharmacy, Texas Health Presbyterian Hospital of Dallas, Dallas, TX, USA Health Science Center, Texas Tech University, Dallas, TX, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Woodard
authors.affiliation: School of Pharmacy, University of California, San Francisco, CA, USA University of Washington Health, Seattle, WA, USA.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Koehl
authors.affiliation: School of Pharmacy, University of California, San Francisco, CA, USA.
authors.forename: William
authors.initials: W
authors.lastname: Mees
authors.affiliation: Manchester Pharmacy School, University of Manchester, Manchester, United Kingdom.
authors.forename: Douglas
authors.initials: D
authors.lastname: Steinke
authors.affiliation: University of Washington Health, Seattle, WA, USA Marin General Hospital, Greenbrae, CA, USA.
authors.forename: Tina Harrach
authors.initials: TH
authors.lastname: Denetclaw
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000818:Animals; D001779:Blood Coagulation Factors / Q000627:therapeutic use*; D019468:Disease Management; D065427:Factor Xa Inhibitors / Q000009:adverse effects*; D005260:Female; D006408:Hematoma, Subdural / Q000139:chemically induced* / Q000175:diagnosis / Q000188:drug therapy*; D006470:Hemorrhage / Q000139:chemically induced / Q000175:diagnosis / Q000188:drug therapy; D006801:Humans; D008297:Male; D000069552:Rivaroxaban / Q000009:adverse effects*
chemical_list: D001779:Blood Coagulation Factors; D065427:Factor Xa Inhibitors; C025667:prothrombin complex concentrates; D000069552:Rivaroxaban
keywords: PCC3; bleeding management; oral anticoagulants; rivaroxaban