Suspected Hematuria: Adverse Effects of Rivaroxaban in Older Adult Treated for Atrial Fibrillation

Abstract

Background: The modern concept of pharmaceutical healthcare implies monitoring the pharmacotherapy outcomes and reporting adverse drug reactions.

Objective: To present a suspected hematuria as the adverse rivaroxaban reaction in a patient with atrial fibrillation observed by pharmacists in a community pharmacy.

Case presentation: A 69-year-old female patient came to a pharmacy with a prescription for cranberry-based supplement. She was diagnosed with a mild urinary infection after experiencing blood in her urine for about two weeks. The pharmaceutical anamnesis revealed that the patient was treated with irbesartan and rivaroxaban. Rivaroxaban was applied for atrial fibrillation, and the patient was treated for nine months. The patient was treated with omeprazole gastro-resistant capsules for mild dyspepsia and stomach ache over a three-week period. The pharmacist counselled the patient to contact the clinician who introduced rivaroxaban, further suggesting substitution with different anticoagulant. Although the urine culture was negative, the physician introduced ciprofloxacin, which was followed by blood in the patient's stool. Thus, gastroscopy, colonoscopy, and gynecological examination were advised. All findings were normal. Four days after rivaroxaban was substituted with acenocoumarol, no blood in the urine or stool was detected.

Conclusions: Rivaroxaban can cause spot urine blood even when applied in therapeutic doses among older female patients when applied with omeprazole. Possible rivaroxaban interaction with omeprazole metabolites is suspected and should be carefully monitored.

Keywords: adverse drug reaction; ciprofloxacin; omeprazole; pharmaceutical healthcare; rivaroxaban.

Figure 1

Timeline of the adverse events and their remission.

Figure 2

Possible mechanism of omeprazole–rivaroxaban interaction.