Fatal intracerebral bleeding under rivaroxaban

Rivaroxaban is a factor-Xa-inhibitor which has been shown to be non-inferior to the vitamin-K-antagonist (VKA) warfarin in atrial fibrillation patients. In the manufacturer-sponsored trial, the rate of intracranial hemorrhage in rivaroxaban-treated patients was lower than in VKA-treated. It is unknown if this advantage of rivaroxaban is also present outside clinical trials. We report a patient with fatal cerebral bleeding 4months after initiation of rivaroxaban. Bleeding might be favored by hypertension, hypoalbuminemia, renal impairment, hepatopathy and drug-drug interactions of rivaroxaban with amiodarone and bisoprolol. Patients have to be monitored closely after initiation of rivaroxaban, especially if they are treated with possibly interacting drugs. Additionally, hepatic function, albumin level, and renal function have to be closely monitored. Therapy with VKA seems more convenient, safer and more favorable for the patient than rivaroxaban with its associated uncertainties concerning metabolization and drug-drug interactions and no possibility to reverse its activity in emergency situations.