Pharmacology · patient case question
How is the anticoagulant effect of rivaroxaban reversed?
Patient case: Choosing and stopping drugs
demo: Series of prescribing decisions
chief: Several patients seen in one session raise questions about antibiotic choice, analgesia and anticoagulation.
history: One patient has a spreading odontogenic infection unresponsive to five days of empirical antibiotics. Another takes rivaroxaban for atrial fibrillation. A third developed a widespread blistering rash and mucosal ulceration a week after starting a new medication.
meds: Varies by patient.
findings: Not applicable.
Show answer and explanation
Correct answer: C. Andexanet alfa, or prothrombin complex concentrate if unavailable
- A. Plasma contains the factors but is not an effective reversal for a direct oral anticoagulant and carries volume and transfusion risks.
- B. Vitamin K reverses warfarin by restoring synthesis of the vitamin K dependent factors II, VII, IX and X. Rivaroxaban does not act on that pathway, so vitamin K is useless against it.
- C. Correct. Rivaroxaban is a direct factor Xa inhibitor. Its specific reversal agent is andexanet alfa, a decoy factor Xa molecule; where that is unavailable, four-factor prothrombin complex concentrate is used. For routine dental extractions no reversal is needed at all, and local haemostatic measures suffice.
- D. Protamine sulfate reverses unfractionated heparin and partially reverses low molecular weight heparin.
Note: The recall keyed this as vitamin K with the author noting real uncertainty. Vitamin K is incorrect. Match the reversal to the mechanism: warfarin with vitamin K, heparin with protamine, dabigatran with idarucizumab, and the Xa inhibitors with andexanet alfa.