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Warfarin and Rivaroxaban Duplication: A Case Report and Medication Error Analysis
Julie A Fusco1, Eric J Paulus2, Alexandra R Shubat3
1Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, 555 31st Street, Downers Grove, IL, 60515, USA. jannfusco@gmail.com.
Drug Safety - Case Reports
|October 18, 2016
Summary
Unintentional duplicate anticoagulation with warfarin and rivaroxaban led to elevated INR. Management involved stopping rivaroxaban and adjusting warfarin, stabilizing the patient without bleeding complications.
Area of Science:
- Pharmacology
- Internal Medicine
- Clinical Pharmacy
Background:
- A patient with recurrent pulmonary embolism was prescribed warfarin.
- Unintentional duplicate therapy with rivaroxaban was initiated.
- This led to a significant elevation in the patient's International Normalized Ratio (INR).
Purpose of the Study:
- To report a case of unintentional duplicate anticoagulation therapy.
- To highlight the potential for drug interactions and management challenges.
- To emphasize the importance of medication reconciliation and patient counseling.
Main Methods:
- A 62-year-old male patient on warfarin 5 mg daily for pulmonary embolism inadvertently received rivaroxaban 20 mg daily.
- The patient presented with supratherapeutic INR (>8.0) without bleeding.
- Management involved discontinuing rivaroxaban, adjusting warfarin dosage, and close INR monitoring.
Main Results:
- The patient's INR was initially 2.3, then rose to >8.0 after starting rivaroxaban.
- Rivaroxaban can falsely elevate INR readings, making the true INR value uncertain.
- After dose adjustment and discontinuation of rivaroxaban, the INR stabilized at 4.3, and the patient was maintained on warfarin 22.5 mg weekly without bleeding.
Conclusions:
- Unintentional duplicate anticoagulation poses a significant risk.
- Clinical pharmacists play a crucial role in identifying and managing such adverse events.
- Improved pharmacy communication and patient education are vital to prevent medication errors.
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