리바록사반 (자렐토)을 복용 중인 환자의 수술 전 약제 중단

리바록사반 (자렐토)는 direct factor Xa inhibitor이며 prothrombin을 thrombin으로 바꾸는 factor Xa의 효소 기능을 가역적으로 막는 역할을 합니다.

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리바록사반은 시술 전 약 2-3일 동안 중단할 수 있는데 출혈 위험이 높은 경우에는 더 길게 중단하고 출혈 위험이 낮은 경우는 짧게 중단합니다. 따라서 출혈 위험이 높은 시술의 경우, 환자는 2회의 리바록사반 (자렐토)을 중단합니다. 즉 수술 2일 전, 1일 전, 수술 당일은 복용하지 않습니다. 이 간격들은 7-11시간의 반감기에 근거를 두며 정상 또는 creatinine clearance >50 mL/minute이면서 하루 20 mg 복용하거나 moderate renal insufficiency (예, creatinine clearance between 30 and 50 mL/minute)이면서 하루 15 mg을 복용하는 사람에 적용합니다.

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Expected effects of anticoagulant drugs on commonly used coagulation tests

Drug class	Drug	Brand name(s)	PT	aPTT	Anti-factor Xa activity
Vitamin K antagonists	Warfarin	Coumadin, Jantoven	↑	↑/–*	–
	Acenocoumarol	Sintrom	↑	↑/–*	–
Heparins	Unfractionated heparin		–¶	↑	↑
	LMW heparins Enoxaparin Dalteparin Nadroparin	Lovenox Fragmin Fraxiparine	–	↑/–	↑
	Fondaparinux	Arixtra	–	↑/–	↑
Direct thrombin inhibitors	Argatroban	Acova	↑	↑	–
	Dabigatran	Pradaxa	↑/–	↑	–
Direct factor Xa inhibitors	Rivaroxaban	Xarelto	↑/–	↑/–	↑Δ
	Apixaban	Eliquis	↑/–	↑/–	↑Δ
	Edoxaban	Lixiana, Savaysa			↑Δ
	Betrixaban	Bevyxxa			↑Δ

PT and aPTT are measured in seconds; anti-factor Xa activity is measured in units/mL. Upward arrow (↑) signifies an increase above normal due to the anticoagulant (prolongation of PT or aPTT; increase in anti-factor Xa activity). The effect magnitude will vary depending on the reagent formulation and instrument used. Dash (–) signifies no appreciable effect. Normal ranges for the PT, aPTT, and anti-factor Xa activity vary among laboratories and should be reported from the testing laboratory along with the patient result. Refer to the UpToDate topic on coagulation testing for details.

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PT: prothrombin time; aPTT: activated partial thromboplastin time; LMW heparin: low molecular weight heparin.

* Warfarin has a weak effect on most aPTT reagents. However, warfarin use will increase the sensitivity of the aPTT to heparin effect.

¶ While heparin, LMW heparin, and fondaparinux should, in theory, prolong the PT as indirect thrombin inhibitors, in practice most PT reagents contain heparin-binding chemicals that block any heparin effect below a concentration of 1 unit/mL. Above concentrations of 1 unit/mL, heparin effect on the PT may be observed.

Δ Anti-factor Xa activity testing must be calibrated for the specific anticoagulant; this information should be verified with the clinical laboratory. Data are not available for betrixaban but would be expected to be similar to other direct factor Xa inhibitors.

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Some of the data are from: Samuelson BT, Cuker A, Crowther M, Garcia DA. Laboratory assessment of the anticoagulant activity of direct oral anticoagulants: A systematic review. Chest 2017; 151:127.