When Apixaban and Rivaroxaban Interfere With Anti-Xa Assays: A Cohort Study

Background: The use of direct factor Xa inhibitors, such as apixaban and rivaroxaban, has improved medication adherence. However, in certain situations during hospital admission, patients on these medications may need to be transitioned to unfractionated heparin (UFH) infusions. This transition can skew results of anticoagulation monitoring, such as the anti-Xa assay, due to residual factor-Xa inhibitor activity. Methods: We conducted this retrospective chart among admitted patients to St. Vincent's Medical Center in Bridgeport, CT between December 2020 till June 2022. Patients who were maintained on Apixaban or Rivaroxaban, factor-Xa inhibitors, and were transitioned to unfractionated intravenous drip were included. A baseline plasma anti-Xa level was noted. Assessment for thrombotic or bleeding events during hospitalization was performed. Results: A total of 48 patients were included in this study. The majority of patients were bridged to UFH for NSTEMI (31%) or pre-procedure (23%). The mean baseline anti-Xa for all patients was 0.92 U/mL. Twelve patients (25%) and one patient (2%) of patients had bleeding and thrombotic events, respectively. Although the mean baseline anti-Xa level was higher for patients who had an adverse event compared to no event, the difference was non-statistically significant. Fifty seven percent of patients who had an adverse event had a supratherapeutic plasma anti-Xa baseline level. A gastrointestinal bleed was the most common type of bleeding event. Conclusions: To prevent thrombotic or bleeding events, we suggest adopting a standard practice of obtaining a baseline anti-Xa level in patients with recent exposure to factor Xa inhibitors in order to guide the timing of UFH initiation, the dosing of heparin, and determine the need for alternative assays, such as the activated partial thromboplastin clotting time.