Dabigatran-related leukocytoclastic vasculitis

Leukocytoclastic Vasculitis: Depiction of the Diagnostic Dilemma

Vasculitis is classified based on the size of the blood vessels involved. Sub-group Leukocytoclastic vasculitis (LCV) refers to small blood vessel inflammation, which involves cutaneous capillaries and venules. To date, there have been myriad primary and secondary probable causes of LCV. Here, we present a case of an 86-year-old male who presented with non-blanchable purpura involving the ankles, knees, and palms. The patient had idiopathic pulmonary fibrosis (IPF), for which he had been on long-term oxygen therapy and chronic corticosteroids. He was recently started on Bactrim DS (trimethoprim-sulfamethoxazole double strength) for prophylaxis of pneumocystis pneumonia. After a meticulous workup, including a skin biopsy, the causative agent of the LCV was established to be Bactrim DS, and the event was likely triggered by superimposed acute stress of sepsis secondary to UTI and bacteremia. There were several diagnostic dilemmas due to the ongoing chronic medical conditions; however, the occurrence of LCV while being on chronic corticosteroids was concerning as it should have prevented such an untoward occurrence. Eventually, the presentation subsided past an increase in the dose of corticosteroids and discontinuation of Bactrim DS. This raises concern regarding either the dose-dependent immunosuppressive effects of corticosteroids or deficits in our current understanding of the mechanism of action. Additionally, it necessitates further exploration into the causes of LCV and a thorough understanding of its pathogenesis.

Colloidal Silver Ingestion Associated with Leukocytoclastic Vasculitis in an Adolescent Female

Patient: Female, 19

Final Diagnosis: Leukocytoclastic vasculitis

Symptoms: Fatigue • joint • pain • muscle • pain • pruritis • rash

Medication: —

Clinical Procedure: —

Specialty: Dermatology

Case of both rivaroxaban- and dabigatran-induced leukocytoclastic vasculitis, during management of pulmonary thromboembolism

Leukocytoclastic vasculitis is a disorder characterized by neutrophilic inflammation that is predominantly limited to the superficial cutaneous postcapillary venules. This condition may be idiopathic or may have a defined cause. Rivaroxaban and dabigatran have been widely used as warfarin alternatives, because of their efficacy and safety. In this case report, we describe a case of leukocytoclastic vasculitis induced by both rivaroxaban- and dabigatran-, which developed during the management of pulmonary thromboembolism.

Non-bleeding Adverse Events with the Use of Direct Oral Anticoagulants: A Sequence Symmetry Analysis

Introduction

Postmarketing pharmacovigilance reports have raised concerns about non-bleeding adverse events associated with direct oral anticoagulants (DOACs), but only limited results are available from large claims databases.

Objective

The aim of this study was to assess the potential association between DOAC initiation and the onset of four types of non-bleeding adverse events by sequence symmetry analysis (SSA).

Methods

SSA was performed using nationwide data from the French National Healthcare databases (Régime Général, 50 million beneficiaries) to assess a cohort of 386,081 DOAC new users for the first occurrence of four types of non-bleeding outcomes: renal, hepatic, skin outcomes identified by using hospitalization discharge diagnoses, and gastrointestinal outcomes by using medication reimbursement. Asymmetry in the distribution of each investigated outcome occurring before and after initiation of DOAC therapy was used to test the association between DOAC therapy and these outcomes. SSA inherently controls for time-constant confounders, and adjusted sequence ratios were computed after correcting for temporal trends. Negative (glaucoma) and positive (bleeding, depressive disorders) control outcomes were used and analyses were replicated on a cohort of 310,195 patients initiating a vitamin K antagonist (VKA).

Results

This study demonstrated the expected positive association between either DOAC or VKA therapy and hospitalised bleeding and initiation of antidepressant therapy, while no association was observed between either DOAC or VKA therapy and initiation of antiglaucoma medications. For DOAC therapy, signals were the associations with hepatic outcomes, including acute liver injury [for the 3-month time window, aSR₃ = 2.71, 95% confidence interval (CI) 1.79–4.52]; gastrointestinal outcomes, including initiation of drugs for constipation and antiemetic drugs (aSR₃ = 1.31, 95% CI 1.27–1.36; and 1.17, 95% CI 1.12–1.22, respectively); and kidney diseases (aSR₃ = 1.33, 95% CI 1.29–1.37).

Conclusion

Results of this nationwide study suggest that DOACs are associated with rare but severe liver injury and more frequent gastrointestinal disorders. A low risk of kidney injury with DOAC therapy can also not be excluded.

Electronic supplementary material

The online version of this article (10.1007/s40264-018-0668-9) contains supplementary material, which is available to authorized users.