Apixaban Causing Leukocytoclastic Vasculitis

Hypersensitivity reaction to rivaroxaban with a successful switch to apixaban: A case report

Key Clinical Message

The precise management of hypersensitivity reactions to direct oral anticoagulants (DOACs) and the potential for cross-reactivity among different DOACs remain unclear. In such cases, switching between DOACs may be feasible and could be considered, but close monitoring for adverse effects is essential, tailored to individual patient responses and tolerability.

Abstract

Hypersensitivity reactions to DOACs, though considered rare, have been documented. This report describes the case of a 28-year-old male with a history of testicular cancer who was recently diagnosed with deep vein thrombosis. He was referred to an outpatient pharmacotherapy clinic due to suspected rivaroxaban-induced cutaneous reactions. Following a thorough evaluation, his anticoagulant therapy was switched from rivaroxaban to apixaban. This change was successfully implemented, and no hypersensitivity symptoms recurred during subsequent follow-up. This case demonstrates the importance of recognizing potential adverse reactions to DOACs and illustrates the feasibility of switching anticoagulants under close medical supervision to ensure patient safety and effective treatment.

Cutaneous Leukocytoclastic Vasculitis Induced by Apixaban and/or Rivaroxaban With Seronegative Anti-Neutrophil Cytoplasmic Antibody (ANCA) Titers: A Case Report and Literature Review

A 45-year-old man presented with a diffuse petechial rash and a non-blanching palpable purpura, mainly on his lower extremities, some of which had coalesced, blistered, and ulcerated. The patient had a history of hypercoagulability and was chronically on anticoagulant medication. The rash appeared a week after starting apixaban 5 mg twice daily by mouth. Prior to that, he was receiving rivaroxaban. The rash was biopsied, which demonstrated cutaneous leukocytoclastic vasculitis (LCV). Serum anti-neutrophil cytoplasmic antibody (ANCA) titers were negative. Complement levels of C3, C4, and CH50 were normal. Hepatitis C antibodies were negative. HIV antibodies were non-reactive. Titers for Lyme disease and Rocky Mountain spotted fever were nonreactive. It is unusual for a drug to induce cutaneous LCV with negative ANCA titers. Although rare, it usually requires aggressive therapy. Our case resolved after the discontinuation of apixaban and rivaroxaban and the initiation of warfarin for hypercoagulability in conjunction with a short course of steroids. As the use of apixaban and rivaroxaban increases, we may see a consequent increase in cutaneous LCV that is specifically ANCA-negative.

Aftermath of Apixaban: Atypical Anticoagulation Aftereffect

An elderly man with prostate cancer and a deep vein thrombosis (DVT) of the lower extremity diagnosed 12 days ago on apixaban presented with a new-onset palpable rash on both of his legs. Extensive laboratory workup was largely unremarkable, except for multiple skin punch biopsies revealing deposition of immunoglobulin A (IgA) in the superficial blood vessels with infiltration of leukocytes, concerning for a small vessel vasculitis. Given the temporal association along with the negative workup, the rash was attributed to apixaban, and the anticoagulation regimen was switched to dabigatran. At a 2-week follow-up visit, the patient was asymptomatic and tolerating dabigatran without any adverse events.

Delayed Vesicular Urticarial Dermatosis Due to Apixaban

Cutaneous adverse drug reactions (cADR) are delayed hypersensitivity reactions that are T-cell mediated. Novel oral anticoagulants, including Factor Xa inhibitors, are increasingly used as therapeutic or prophylactic management of thrombosis and atrial fibrillation.

We introduce the case of a 78-year-old woman with no known allergies and a history of atrial fibrillation who was started on apixaban for cerebrovascular accident prophylaxis. Approximately nine days after starting apixaban, she developed a vesicular-urticated erythematous rash initially located on her right upper extremity, progressing to her face. She was evaluated after two weeks for the persistence of symptoms and improved with hydroxyzine and prednisone. Subsequently, she was advised to discontinue and evade all Factor Xa inhibitors, including apixaban, and was switched to warfarin.

Naranjo score scale was 5-6. The patient declined skin biopsy and drug challenge. After a month of discontinuation of systemic steroids, patch testing was performed with apixaban, rivaroxaban, and edoxaban, with a negative result. Since this episode, the patient has not had a recurrence of the rash.

As far as we know, this is the first case report of a non-severe cADR to apixaban. Even though there are no standardized protocols for diagnosing drug reactions to Factor Xa inhibitors, patch testing at increasing non-irritant concentrations with re-challenge of alternative agents and the suspected offending agent, if possible, should be included in the evaluation of a cADR.

Possible apixaban-induced leukocytoclastic vasculitis

PURPOSE

The development of leukocytoclastic vasculitis (LCV) during apixaban therapy in a female patient being treated for deep vein thrombosis (DVT) is reported.

SUMMARY

A 74-year-old Caucasian woman weighing 102 kg presented to a walk-in clinic with complaints of mild pain and swelling in her left leg for 2 weeks. She was diagnosed as having left lower-extremity DVT. The direct oral anticoagulant (DOAC) apixaban (10 mg twice daily for 7 days, then 5 mg twice daily for 3 months) was prescribed. At 1-week follow-up the patient stated that her DVT symptoms were slowly improving and reported that small areas of red rash had appeared bilaterally on her lower extremities. On day 23 of apixaban therapy, the patient presented to a walk-in clinic with a complaint that the rash had progressively worsened. The rash was diagnosed as LCV by dermatology consult. On day 24 of therapy, apixaban use was discontinued and the patient was initiated on rivaroxaban (20 mg daily) for the remainder of DVT treatment. LCV was found to be progressively improving on day 73, with trace petechiae. Rivaroxaban was used through the end of DVT treatment without further reports of LCV.

CONCLUSION

A female patient who developed LCV while taking apixaban for treatment of DVT was successfully transitioned to rivaroxaban therapy, leading to resolution of LCV and successful completion of DVT treatment without recurrence of LCV.

Drug-Induced Lupus with Leukocytoclastic Vasculitis Associated with Apixaban

Drug-induced lupus is an iatrogenic-induced autoimmune disease with common offending agents well documented in the literature. To our knowledge, there are no prior case reports of drug-induced lupus associated with apixaban or any other direct oral anticoagulant. We describe a case of drug-induced lupus with leukocytoclastic vasculitis associated with apixaban started 15 days prior, after a WATCHMAN procedure for atrial fibrillation in an 86-year-old male previously anticoagulated on rivaroxaban.

A 78-Year-Old Man with a Pulmonary Embolism Who Developed Skin Necrosis 7 Days After Treatment with the Direct Oral Anticoagulant Factor Xa Inhibitor Apixaban

BACKGROUND Apixaban is one of the newer direct oral anticoagulants (DOACs) being used to manage venous thrombosis. Skin toxicities are recognized adverse effects of the new DOACs, but are rare and usually associated with vasculitis. This report is of a 78-year-old man admitted to the hospital with pulmonary thromboembolism, who developed severe and extensive skin necrosis of both forearms 7 days after treatment with apixaban. CASE REPORT A 78-year-old man was admitted for pulmonary embolism and congestive heart failure exacerbation. He was started on therapeutic enoxaparin and diuresis. Later on, enoxaparin was substituted with apixaban. Seven days after starting apixaban, he suddenly developed skin changes that developed into skin necrosis on both forearms and the abdominal wall. A skin biopsy was not performed due to the high risk of bleeding. Skin necrosis was diagnosed based on clinical findings. A review of clinical data and the patient's medication profile did not reveal any other possible etiology or culprit medication. Clinical presentation and lab values were not consistent with infections or autoimmune etiologies. Apixaban was discontinued as it was perceived to be the likely cause of skin necrosis. The skin changes gradually improved within 1 week with supportive wound care, and the patient did not require a skin graft. The patient was discharged safely with subcutaneous low-molecular-weight heparin therapy. CONCLUSIONS This report shows that skin toxicity can be associated with apixaban and that with the increasing use of these newer DOACs, clinicians should be aware of these potential adverse effects.

Complementary Use of U.S. FDA's Adverse Event Reporting System and Sentinel System to Characterize Direct Oral Anticoagulants-Associated Cutaneous Small Vessel Vasculitis

BACKGROUND

Cutaneous small vessel vasculitis (CSVV) has been reported after exposure to direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and edoxaban.

OBJECTIVE

We used the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) to describe clinical characteristics associated with CSVV among DOAC-exposed patients. Furthermore, we characterized this signal in the Sentinel System to relate the clinical data from the individual FAERS cases to population-based electronic healthcare data.

METHODS

We queried FAERS for all cases of CSVV associated with DOACs from U.S. approval date of each DOAC through March 16, 2018. Within the Sentinel System, we identified incident CSVV cases using ICD-9 and ICD-10 diagnosis codes among adults aged ≥ 30 years who received a DOAC in the prior 90 days between January 1, 2010, and June 30, 2018. We excluded patients with evidence of select autoimmune diagnoses in the 183 days prior to their CSVV diagnoses and reported patient characteristics in the 183-day period prior to CSVV diagnoses.

RESULTS

In FAERS, we identified 50 cases of CSVV reported with rivaroxaban (n=26), apixaban (n=14), dabigatran (n=9), and edoxaban (n=1). Approximately 50% of the cases reported time to onset within 10 days after DOAC exposure. When specified, the predominant type of CSVV reported was leukocytoclastic vasculitis (n=31), followed by Henoch-Schonlein purpura (n=4). Hospitalization occurred in most of the cases (n=37). Switching of the offending agent after the development of CSVV was reported (n=26). Three rivaroxaban (n=3) cases and one dabigatran case (n=1) reported positive rechallenge. In the Sentinel system, we identified 3659 CSVV cases with prior DOAC exposure, with 85% of events occurring within 10 days.

CONCLUSIONS

The assessment of FAERS cases, combined with the temporal clustering of the Sentinel System cases suggest a possible causal relationship of DOACs and CSVV. Future efforts should characterize the risk of CSVV among the various DOAC users.

A rare case report of apixaban-induced lichenoid eruption

With recent increase in the use of direct oral anticoagulants (DOACs), several new cases of adverse drug reactions (ADRs) have been identified in pharmacovigilance surveys. These ADRs can result in significant mortality and morbidity if not identified and treated promptly. It is important for physicians to recognize that immunologically mediated delayed hypersensitivity reactions, although rare in occurrence, can have significant impact on patient's quality of life. To the best of our knowledge, we report the first case of lichenoid eruption associated with apixaban. We further provide evidence of tolerance to rivaroxaban in the same patient.

PLAIN LANGUAGE SUMMARY

Apixaban-induced lichenoid eruption Well documented case reports, although providing evidence of probable causal relationship between a drug and specific adverse drug reactions (ADRs), can increase awareness amongst clinicians treating patients with direct oral anticoagulants (DOACs), especially with its rapid utilization. Rare ADRs are difficult to detect as clinical trials of DOACs lacked enough patient sample, making post-marketing reporting of such events important so both patients and clinicians can be vigilant to help with prompt recognition of such symptoms. We report the first case of lichenoid eruption hypersensitivity reaction associated with apixaban in patient with tolerance to rivaroxaban.

Apixaban as a Rare Cause of Leukocytoclastic Vasculitis

Apixaban is a rare cause of leukocytoclastic vasculitis (LCV). To our knowledge, there is only one other reported case due to apixaban in the literature. We present a case of apixaban-induced leukocytoclastic vasculitis in a 95-year-old male. He had been started on apixaban 12 days prior to presentation and developed worsening palpable purpura of his lower extremities. Possible etiologies of this new rash were excluded, with biopsy showing extensive purpura with superficial perivascular neutrophilic infiltrate and leukocytoclasis. Apixaban was discontinued, and the patient was started on a slow prednisone taper with subsequent resolution of his rash.