Acute liver failure after changing oral anticoagulant from apixaban to rivaroxaban

Rivaroxaban is a commonly used anticoagulant agent for treatment and prevention of thromboembolism. There are case reports demonstrating an association between its use and drug-induced liver injury. However, this has not been reported in a patient who previously tolerated apixaban. An 88-year-old man presented to hospital with worsening lethargy, jaundice and vomiting. He had severely elevated liver transaminases, an abnormal coagulation profile and elevated bilirubin in keeping with acute liver injury. This is in the context of having had his anticoagulation medication switched from apixaban to rivaroxaban 2 weeks prior. The patient recovered well after cessation of rivaroxaban, suggesting that it was the likely offending agent. The mechanism of rivaroxaban-induced liver injury remains to be investigated. Drug-induced liver injury should be discussed and monitored for as a potential adverse reaction when commencing rivaroxaban, even if a patient has previously tolerated a drug of the same class.