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VTE Case Presentation 通過 單一口服抗凝劑(Rivaroxaban)治療急性深部靜脈栓塞之單一醫院經驗
Monotherapy with Novel Oral Anticoagulant (Rivaroxaban) in Acute Deep Venous Thrombosis-Single Hospi
Purpose: Conventionally, two-anticoagulant “bridging” regimen is the standard therapy of symptomatic deep venous thrombosis (DVT). In the initial treatment of acute DVT, fast-onset parenteral heparin (either UFH or LMWH) and slow-onset oral warfarin (a vitamin K antagonist, VKA) are used together to effectively reduce clot formation as well as prevent thrombus propagation. As therapeutic serum level of VKA is achieved, oral warfarin can be used alone for the subsequent treatment. However, such a bridging regimen is not accessible for both patients and health care members. Frequent aPTT and PT/INR monitor with concurrent adjustment of drug dose usually increase health workers’ burden and decrease patients’ compliance. Moreover, drug-drug and drug-food interactions often interfere with the efficacy of warfarin. Therefore, simple-used, fixed-dose, monitor-free and less-interacted anticoagulant is demanded for managing thromboembolic diseases. Rivaroxaban (Factor Xa inhibitor) is a newly developed oral anticoagulant which meets abovementioned requirements and has been proved eligible in the treatment of venous thromboembolism. Our purpose of this study is to investigate the feasibility of single drug approach for DVT by using Rivaroxaban. Materials and Methods: Twelve patients who were diagnosed acute DVT after total knee replacement with ultrasonography and elevated serum D-Dimmer (> 3500 ng/dl) were recruited in this prospective study. Eight patients were given Rivaroxaban 10mg/qd since the initial time of referral and the rest four patients were prescribed 20mg/qd. All twelve patients had been followed up more than 3 months and the longest one had reached to 6 months. Regular D-Dimmer checking (7 days, 14 days, 28 days, 56 days and further every month) and repeated ultrasonography (at least two times for each patient) were conducted to assess if thrombus resolved, persisted or relapsed. We didn’t conform to the protocol of EISTEIN study which suggests 30mg/bid of Rivaroxaban during the first 21 days and then shifts to 20mg/qd for the subsequent 3 or more months. Prescription of 10 mg/qd Rivaroxaban was in accordance with the payment indications of National Health Insurance Administration that allows 10 mg/qd dose using at DVT patients following total knee/hip arthroplasty. As for the four patients receiving 20 mg/qd, they paid the additional fee of 10 mg/qd by themselves. Results: Symptoms and signs of DVT, e.g. leg swelling and Homan’s sign, subsided around 7 to 14 days after Rivaroxaban taking in all patients. However, restoration of D-Dimmer to normal level (< 278 ng/dl at our hospital) needs longer time for 10 mg/qd patients than that for 20 mg/qd patients (average 18.5 days v.s. 13.2 days). One 10 mg/qd patient’s D-Dimmer rose again (up to 675 ng/dl) and later returned to normal with the same dose of Rivaroxaban, but he didn’t develop obvious symptom and sign as before. Almost all patients’ ultrasonographic images demonstrated thrombus-free while D-Dimmer level decreased to 550-600 ng/dl except one 10 mg/qd patient still had residual organized thrombus. D-Dimmer level of this patient was normal when she underwent follow-up ultrasonography. No thrombus relapsing or recurrent symptomatic DVT was noted in all patients. Conclusion: From our limited experience, single drug approach with Rivaroxaban is feasible in treating acute DVT after total knee replacement (a kind of provoked DVT). Moreover, lower dose (10 or 20 mg/qd) of Rivaroxaban seems also to be effective for dealing with such kind provoked DVT.