Idiosyncratic liver injury due to rivaroxaban

Rivaroxaban is an oral direct factor Xa inhibitor that has been used for the primary and secondary prophylaxis of thromboembolic disorders. Once daily dosing makes it an attractive alternative when compared to other Novel Oral Anticoagulants (NOACS). Although, major and minor bleeding manifestations are commonly associated with rivaroxaban, hepatotoxicity has also been mentioned in the literature as a possible adverse effect. We report a case of drug induced liver injury in a 29-year-old male patient who was started on rivaroxaban for prophylaxis following an episode of Pulmonary Thromboembolism (PTE). There was a strong temporal relationship between the onset of symptoms and drug exposure in our case and the association was further validated by standard criteria. Roussel Uclaf Causality Assessment Method (RUCAM) score of 7 suggests rivaroxaban as the ‘probable’ culprit for drug induced liver injury in the present case. The temporal association of starting rivaroxaban and onset of symptoms along with elevated liver enzymes and bilirubin is a strong point in favour of drug induced liver injury due to rivaroxaban.