Volume 9 ; Issue 2 ; in Month : July-Dec (2026) Article No : 182
Sethi K, Braverman D, Veltri KT.

Abstract

Direct oral anticoagulants (DOACs) have transformed anticoagulation therapy by offering a convenient alternative to vitamin K antagonists such as warfarin. Apixaban and rivaroxaban have simplified treatment of thromboembolic conditions, including deep vein thrombosis (DVT) and atrial fibrillation, through predictable pharmacokinetics, fewer drug and dietary interactions, and no requirement for routine coagulation monitoring. Both agents are direct, selective inhibitors of activated factor Xa, which plays a key role in converting prothrombin to thrombin. Although generally well tolerated, DOACs have been associated with rare hypersensitivity reactions, including rash, urticaria, pruritus, and angioedema. Because apixaban and rivaroxaban share a common pharmacologic target, potential cross-reactivity is a clinical concern. However, evidence is limited primarily to case reports, and clear guidance on managing these reactions is lacking. We present a case of suspected cross-reactivity between apixaban and rivaroxaban in an 80-year-old man with multiple comorbidities, including stage 3 chronic kidney disease, hypertension, type 2 diabetes, and hypercholesterolemia. During hospitalization for pneumonia, he was diagnosed with a right lower-extremity DVT and started on apixaban. He subsequently developed severe pruritus, esophageal discomfort, and dry mouth without another apparent cause. Apixaban was discontinued and replaced with rivaroxaban; within days, he developed generalized itching, bloating, palpitations, esophageal tightness, and erythema around the left ankle. Due to intolerance to both agents, he was transitioned to warfarin with an enoxaparin bridge. His symptoms improved following discontinuation of rivaroxaban, and he was discharged on warfarin with plans for INR monitoring.

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