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Rivaroxaban

Medically reviewed on August 12, 2018

Pronunciation

(riv a ROX a ban)

Index Terms

  • BAY 59-7939
  • Non-Vitamin K Antagonist Oral Anticoagulant (NOAC) (error-prone acronym)

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Xarelto: 10 mg, 15 mg, 20 mg

Tablet Therapy Pack, Oral:

Xarelto Starter Pack: 15 mg (42s) and 20 mg (9s) (51 ea)

Brand Names: U.S.

  • Xarelto
  • Xarelto Starter Pack

Pharmacologic Category

  • Anticoagulant
  • Anticoagulant, Factor Xa Inhibitor
  • Direct Oral Anticoagulant (DOAC)

Pharmacology

Inhibits platelet activation and fibrin clot formation via direct, selective and reversible inhibition of factor Xa (FXa) in both the intrinsic and extrinsic coagulation pathways. FXa, as part of the prothrombinase complex consisting also of factor Va, calcium ions, factor II and phospholipid, catalyzes the conversion of prothrombin to thrombin. Thrombin both activates platelets and catalyzes the conversion of fibrinogen to fibrin.

Absorption

Rapid

Distribution

Vdss: ~50 L

Metabolism

Hepatic via CYP3A4/5 and CYP2J2

Excretion

Urine (66% primarily via active tubular secretion [~36% as unchanged drug; 30% as inactive metabolites]); feces (28% [7% as unchanged drug; 21% as inactive metabolites])

Time to Peak

Plasma: 2 to 4 hours

Half-Life Elimination

Terminal: 5 to 9 hours; Elderly: 11 to 13 hours

Protein Binding

~92% to 95% (primarily to albumin)

Special Populations: Renal Function Impairment

Rivaroxaban exposure is increased by 44% in patients with mild impairment (CrCl 50 to 79 mL/minute) and by 52% in patients with moderate impairment (CrCl 30 to 49 mL/minute). In patients with moderate renal impairment, a 1.86-fold increase in the AUC for factor Xa inhibition and a 2.16-fold increase in PT prolongation was observed (Kubitza 2010).

Special Populations: Hepatic Function Impairment

Significant increases in rivaroxaban exposure were observed in subjects with moderate hepatic impairment (Child-Pugh class B). Increases in pharmacodynamic effects were also observed. No clinical data are available for patients with severe hepatic impairment.

Special Populations: Elderly

Elderly patients exhibit higher plasma concentrations than younger patients, with mean AUC values being ~50% higher, mainly because of reduced (apparent) total body and renal clearance.

Special Populations: Race

Healthy Japanese subjects were found to have 20% to 40% higher exposures compared with other ethnicities, including Chinese subjects.

Use: Labeled Indications

Indefinite anticoagulation (reduced intensity dosing against venous thromboembolism recurrence): Reduction in the risk of recurrence of DVT and PE in patients at continued risk of DVT and PE following at least 6 months of initial full therapeutic anticoagulant treatment for DVT and/or PE

Nonvalvular atrial fibrillation: Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (AF)

Venous thromboembolism (deep vein thrombosis or pulmonary embolism): Treatment of DVT or PE

Venous thromboembolism prophylaxis in total hip or knee arthroplasty: Postoperative thromboprophylaxis of DVT, which may lead to PE in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA)

Off Label Uses

Heparin-induced thrombocytopenia (treatment)

Data from case series, small prospective cohort studies, and a systematic review suggest that rivaroxaban may be used in the management of patients with heparin-induced thrombocytopenia (HIT) [Linkins 2016], [Shatzel 2016], [Warkentin 2017]. The optimal use of rivaroxaban in management of HIT is unknown and therefore, dosing recommendations cannot be made at this time due to paucity of data. However, some suggest using the dosing regimen recommended for the treatment of acute venous thromboembolism as either initial therapy of acute HIT in selected hemodynamically stable patients or after initial therapy with a parenteral non-heparin anticoagulant [Coutre 2018].

Superficial vein thrombosis, acute symptomatic

Data from a small phase 3b, open-label, randomized, double-blind trial support the use of rivaroxaban in the treatment of superficial vein thrombosis, particularly if there is involvement of the great saphenous vein, a ≥5 cm segment is affected, or other risk factors for venous thromboembolism are present [Beyer-Westendorf 2017]. Additional trials may be necessary to further define the role of rivaroxaban in this condition.

Contraindications

Severe hypersensitivity to rivaroxaban or any component of the formulation; active pathological bleeding

Canadian labeling: Additional contraindications (not in US labeling): Hepatic disease (including Child-Pugh classes B and C) associated with coagulopathy and clinically relevant bleeding risk; lesions or conditions at increased risk of clinically significant bleeding (eg, hemorrhagic or ischemic cerebral infarction, spontaneous or acquired impairment of hemostasis, active peptic ulcer disease with recent bleeding); concomitant systemic treatment with strong CYP3A4 and P-glycoprotein (P-gp) inhibitors (eg, ketoconazole, itraconazole, posaconazole, ritonavir); concomitant use with any other anticoagulant including unfractionated heparin (except at doses used to maintain central venous or arterial catheter patency), low molecular weight heparins (eg, enoxaparin, dalteparin) or heparin derivatives (eg, fondaparinux); concomitant use with warfarin, dabigatran, edoxaban, or apixaban except when switching therapy to or from rivaroxaban; pregnancy; lactation

Dosing: Adult

Nonvalvular atrial fibrillation (AF) (to prevent stroke and systemic embolism): Oral: 20 mg once daily with the evening meal.

Post-percutaneous coronary intervention with stent placement and nonvalvular AF (alternative regimen) (off-label dosing): Note: For use as an alternative to triple antithrombotic therapy (ie, dual antiplatelet therapy plus warfarin) in patients with varying levels of thrombotic and bleeding risk. Patients with history of TIA or stroke were excluded from the clinical trial.

Oral: 15 mg once daily with food in combination with clopidogrel (Gibson 2016). Upon completion of this rivaroxaban and clopidogrel regimen, patient should be transitioned to the recommended rivaroxaban dosing for nonvalvular AF. Note: In most cases, clopidogrel is the preferred P2Y12 inhibitor, over prasugrel and ticagrelor, for this situation due to lower risk of bleeding (Sarafoff 2018).

Superficial vein thrombosis, acute symptomatic (off-label use): Note: For use in patients at increased risk for thromboembolism or with recurrent superficial vein thrombosis: Oral: 10 mg once daily for 45 days (Beyer-Westendorf 2017).

Venous thromboembolism (VTE):

Deep vein thrombosis (DVT) and pulmonary embolism (PE) treatment: Note: For initial therapy, without prior treatment with a parenteral anticoagulant (in hemodynamically stable patients without extensive clot burden) or as transition from a parenteral anticoagulant.

Oral: 15 mg twice daily with food for 21 days followed by 20 mg once daily with food. Note: In patients with active cancer, rivaroxaban has not been well studied; another anticoagulant (eg, low-molecular-weight heparin [LMWH], edoxaban) is likely more appropriate (ACCP [Kearon 2016]; Raskob 2017).

Duration of therapeutic anticoagulation (first episode, general recommendations): Optimal duration of therapy is unknown and is dependent on many factors, such as whether provoking events were present, patient risk factors for recurrence and bleeding, and individual preferences:

Provoked VTE: 3 months (provided the provoking risk factor is no longer present) (ACCP [Kearon 2016])

Unprovoked PE or DVT (proximal or isolated distal): ≥3 months depending on risk of VTE recurrence and bleeding. (ACCP [Kearon 2012]; ACCP [Kearon 2016]; ISTH [Baglin 2012]).

Note: All patients receiving indefinite therapeutic anticoagulation with no specified stop date should be reassessed at periodic intervals.

Indefinite anticoagulation (reduced intensity dosing for prophylaxis against VTE recurrence): Note: For patients at elevated risk of recurrent VTE following at least 6 months of therapeutic anticoagulation. This reduced-intensity regimen is not recommended if indefinite full anticoagulation is indicated (Crowther 2017; Lip 2018): Oral: 10 mg once daily (Weitz 2017).

VTE prophylaxis:

Total hip (THA) or knee (TKA) arthroplasty (alternative to LMWH): Oral: 10 mg once daily initiated at least 6 to 10 hours after surgery or when hemostasis established.

Duration: Optimal duration of prophylaxis is unknown but it is usually given for a minimum of 10 to 14 days and can be extended for up to 35 days (Eikelboom 2001; Falck-Ytter 2012); some experts suggest a duration in the lower end of the range (10 to 14 days) for TKA or higher end of range (30 days) for THA (Pai 2018).

Note: In patients at low risk of VTE who are undergoing elective, unilateral THA or TKA, an alternative approach to prophylaxis is to give rivaroxaban 10 mg once daily for 5 days then switch to aspirin for an additional 30 days for THA or 9 days for TKA (Anderson 2018). Limit this strategy to patients who undergo elective unilateral THA or TKA, ambulate within 24 hours after surgery and who have none of the following: additional risk factors for VTE, indications for long-term anticoagulation, lower limb or hip fracture in the previous 3 months, or expected major surgery in the upcoming 3 months (Pai 2018).

Transitioning between anticoagulants: Note: This provides general guidance on transitioning between anticoagulants; also refer to local protocol for additional detail:

Transitioning from another anticoagulant to rivaroxaban:

Transitioning from LMWH or fondaparinux (therapeutic dose) to rivaroxaban:

General transition recommendation: Start rivaroxaban within 2 hours prior to the next scheduled dose of the parenteral agent.

VTE initial treatment transition (alternate recommendation): For acute VTE, some experts start rivaroxaban within 6 to 12 hours after the last dose of a twice daily LMWH regimen or within 12 to 24 hours after a once daily regimen (Hull 2018); for nonacute VTE a general transition strategy is appropriate.

Transitioning from argatroban, bivalirudin, or unfractionated heparin (UFH) continuous infusion to rivaroxaban: Start rivaroxaban when the parenteral anticoagulant infusion is stopped (consult local protocol if aPTT is above the target range) (Bethea 2017; Davis 2017; Tran 2018).

Transitioning from warfarin to rivaroxaban: Discontinue warfarin and initiate rivaroxaban as soon as INR falls to <3 (US labeling) or ≤2.5 (Canadian labeling). Some experts recommend transitioning to rivaroxaban when the INR is therapeutic and as close to 2 as possible to avoid subtherapeutic anticoagulation (Hull 2018).

Transitioning from rivaroxaban to another anticoagulant:

Transitioning from rivaroxaban to UFH continuous infusion, LMWH, or fondaparinux: Start the parenteral anticoagulant when the next dose of rivaroxaban was scheduled to be given.

Transitioning from rivaroxaban to warfarin: Rivaroxaban can elevate the INR and can complicate INR interpretation if therapy is overlapped (Moore 2015). Some experts overlap rivaroxaban with warfarin for 2 or more days. Another alternative is to stop rivaroxaban, start warfarin the same day, and bridge with a parenteral anticoagulant if indicated until the desired INR is reached (Manning 2018).

Transitioning between direct oral anticoagulants (DOACs): Start new DOAC when the next dose of previous DOAC was scheduled to be given.

Transitioning between anticoagulants in the perioperative setting: see 2017 AHA Scientific Statement, “Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting” 2017.

Dosing: Geriatric

Refer to adult dosing. In older adults with CrCl between 30 and 50 mL/minute, reduce dose (specific dosage adjustment not provided). In older adults with CrCl <30 mL/minute, avoid use due to increased risk of bleeding (Beers Criteria [AGS 2015]).

Dosing: Obesity

In patients with a BMI >40 kg/m2 or weight >120 kg, the International Society on Thrombosis and Haemostasis (ISTH) 2016 guideline suggests avoiding the use of rivaroxaban (and other direct oral anticoagulants [DOACs]) due to the lack of clinical data in this population (ISTH [Martin 2016]). A 2017 review concluded, based on pharmacokinetic data, that for individuals with a BMI >40 kg/m2 (or weight >120 kg), rivaroxaban may be used and dosage adjustment is not necessary; however, studies were not powered to address outcomes (Moore 2017).

If used in a patient with a BMI >40 kg/m2 or weight >120 kg, ISTH suggests measuring peak and trough levels using an anti-factor Xa assay or mass spectrometry. If drug level is below the expected range, ISTH suggests changing to a vitamin K antagonist rather than adjusting the dose of rivaroxaban (ISTH [Martin 2016]).

Administration

Administer doses ≥15 mg with food; dose of 10 mg may be administered without regard to meals. For nonvalvular atrial fibrillation, administer with the evening meal. For patients who cannot swallow whole tablets, the tablets (all strengths) may be crushed and mixed with applesauce immediately prior to use; immediately follow administration of the 15 mg and 20 mg tablets with food (10 mg tablets may be administered without regards to food).

For nasogastric/gastric feeding tube administration, the tablets (all strengths) may be crushed and mixed in 50 mL of water; administer the suspension within 4 hours of preparation and follow administration of the 15 mg and 20 mg tablets immediately with enteral feeding (10 mg tablets may be administered without regards to food). Avoid administration distal to the stomach; a decrease in the AUC and Cmax (29% and 56%, respectively) was observed when rivaroxaban was delivered to the proximal small intestine; further decreases may be seen with delivery to the distal small intestine or ascending colon.

Missed doses: Patients receiving 15 mg twice daily dosing who miss a dose should take a dose immediately to ensure 30 mg of rivaroxaban is administered per day (two 15 mg tablets may be taken together); resume therapy the following day as previously taken. Patients receiving once-daily dosing who miss a dose should take a dose as soon as possible on the same day; resume therapy the following day as previously taken.

Storage

Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).

Drug Interactions

Agents with Antiplatelet Properties (e.g., P2Y12 inhibitors, NSAIDs, SSRIs, etc.): May enhance the anticoagulant effect of Rivaroxaban. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor. Monitor therapy

Anticoagulants: May enhance the anticoagulant effect of Rivaroxaban. Refer to separate drug interaction content and to full drug monograph content regarding use of rivaroxaban with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Exceptions: Acenocoumarol; Warfarin. Avoid combination

Antiplatelet Agents (P2Y12 Inhibitors): May enhance the adverse/toxic effect of Rivaroxaban. Specifically, the risk of bleeding may be increased. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor. Consider therapy modification

Apixaban: May enhance the anticoagulant effect of Anticoagulants. Refer to separate drug interaction content and to full drug monograph content regarding use of apixaban with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Avoid combination

Aspirin: May enhance the adverse/toxic effect of Rivaroxaban. Specifically, the risk of bleeding may be increased. Management: Carefully consider risks and benefits of this combination and monitor closely. Consider therapy modification

Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Bromperidol: May enhance the adverse/toxic effect of Anticoagulants. Monitor therapy

Clarithromycin: May increase the serum concentration of Rivaroxaban. Management: In patients with impaired renal function, clarithromycin should not be used unless the potential benefits outweigh the potential risks. This interaction is unlikely clinically significant in patients with normal renal function. Consider therapy modification

Cobicistat: May increase the serum concentration of Rivaroxaban. Avoid combination

Collagenase (Systemic): Anticoagulants may enhance the adverse/toxic effect of Collagenase (Systemic). Specifically, the risk of injection site bruising and/or bleeding may be increased. Monitor therapy

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

CYP3A4 Inducers (Strong): May decrease the serum concentration of Rivaroxaban. Avoid combination

Dabigatran Etexilate: May enhance the anticoagulant effect of Anticoagulants. Refer to separate drug interaction content and to full drug monograph content regarding use of dabigatran etexilate with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Avoid combination

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification

Dasatinib: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Deferasirox: Anticoagulants may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Monitor therapy

Deoxycholic Acid: Anticoagulants may enhance the adverse/toxic effect of Deoxycholic Acid. Specifically, the risk for bleeding or bruising in the treatment area may be increased. Monitor therapy

Edoxaban: May enhance the anticoagulant effect of Anticoagulants. Refer to separate drug interaction content and to full drug monograph content regarding use of edoxaban with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Management: Some limited combined use may be indicated during periods of transition from one anticoagulant to another. See the full edoxaban drug monograph for specific recommendations on switching anticoagulant treatment. Avoid combination

Erythromycin (Systemic): May increase the serum concentration of Rivaroxaban. Management: In patients with impaired renal function, erythromycin should not be used unless the potential benefits outweigh the potential risks. This interaction is unlikely clinically significant in patients with normal renal function. Consider therapy modification

Estrogen Derivatives: May diminish the anticoagulant effect of Anticoagulants. More specifically, the potential prothrombotic effects of some estrogens and progestin-estrogen combinations may counteract anticoagulant effects. Management: Carefully weigh the prospective benefits of estrogens against the potential increased risk of procoagulant effects and thromboembolism. Use is considered contraindicated under some circumstances. Refer to related guidelines for specific recommendations. Exceptions: Tibolone. Consider therapy modification

Factor X (Human): Anticoagulants (Inhibitors of Factor Xa) may diminish the therapeutic effect of Factor X (Human). Monitor therapy

Fat Emulsion (Fish Oil Based): May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of Rivaroxaban. Management: Consider alternatives to this combination when possible. Rivaroxaban dose adjustments may be required when used with systemic fusidic acid. Patients using this combination should be monitored extra closely. Consider therapy modification

Hemin: May enhance the anticoagulant effect of Anticoagulants. Avoid combination

Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry): May enhance the adverse/toxic effect of Anticoagulants. Bleeding may occur. Consider therapy modification

Ibritumomab Tiuxetan: Anticoagulants may enhance the adverse/toxic effect of Ibritumomab Tiuxetan. Both agents may contribute to an increased risk of bleeding. Monitor therapy

Ibrutinib: May enhance the adverse/toxic effect of Anticoagulants. Monitor therapy

Inhibitors of CYP3A4 (Moderate) and P-glycoprotein: May increase the serum concentration of Rivaroxaban. Management: No action is needed in patients with normal renal function. US labeling recommends avoidance in patients with estimated creatinine clearance 15 to 80 mL/min unless prospective benefits outweigh the risks. Other non-US labels may differ. Consider therapy modification

Inhibitors of CYP3A4 (Strong) and P-glycoprotein: May increase the serum concentration of Rivaroxaban. Exceptions: Clarithromycin. Avoid combination

Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Limaprost: May enhance the adverse/toxic effect of Anticoagulants. The risk for bleeding may be increased. Monitor therapy

MiFEPRIStone: May enhance the adverse/toxic effect of Anticoagulants. Specifically, the risk of bleeding may be increased. Avoid combination

Nevirapine: May decrease the serum concentration of Rivaroxaban. Monitor therapy

Nintedanib: Anticoagulants may enhance the adverse/toxic effect of Nintedanib. Specifically, the risk for bleeding may be increased. Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Nonsteroidal Anti-Inflammatory Agents (Nonselective): May enhance the adverse/toxic effect of Rivaroxaban. Specifically, the risk of bleeding may be increased. Management: A comprehensive risk to benefit assessment should be done for all patients before any concurrent use of rivaroxaban and nonsteroidal anti-inflammatory drugs (NSAIDs). If combined, monitor patients extra closely for signs and symptoms of bleeding. Consider therapy modification

Obinutuzumab: Anticoagulants may enhance the adverse/toxic effect of Obinutuzumab. Specifically, the risk of serious bleeding-related events may be increased. Monitor therapy

Omacetaxine: Anticoagulants may enhance the adverse/toxic effect of Omacetaxine. Specifically, the risk for bleeding-related events may be increased. Management: Avoid concurrent use of anticoagulants with omacetaxine in patients with a platelet count of less than 50,000/uL. Avoid combination

Omega-3 Fatty Acids: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Oritavancin: May diminish the therapeutic effect of Anticoagulants. Specifically, oritavancin may artificially increase the results of laboratory tests commonly used to monitor anticoagulant effectiveness, which could lead to incorrect decisions to decrease anticoagulant doses. Monitor therapy

Pentosan Polysulfate Sodium: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Pitolisant: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Combined use of pitolisant with a CYP3A4 substrate that has a narrow therapeutic index should be avoided. Other CYP3A4 substrates should be monitored more closely when used with pitolisant. Consider therapy modification

Progestins: May diminish the therapeutic effect of Anticoagulants. More specifically, the potential prothrombotic effects of some progestins and progestin-estrogen combinations may counteract anticoagulant effects. Management: Carefully weigh the prospective benefits of progestins against the potential increased risk of procoagulant effects and thromboembolism. Use is considered contraindicated under some circumstances. Refer to related guidelines for specific recommendations. Consider therapy modification

Prostacyclin Analogues: May enhance the adverse/toxic effect of Anticoagulants. Specifically, the antiplatelet effects of these agents may lead to an increased risk of bleeding with the combination. Monitor therapy

Salicylates: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

St John's Wort: May decrease the serum concentration of Rivaroxaban. Avoid combination

Sugammadex: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Sulodexide: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Telavancin: May diminish the therapeutic effect of Anticoagulants. Specifically, telavancin may artificially increase the results of laboratory tests commonly used to monitor anticoagulant effectiveness, which could lead to incorrect decisions to decrease anticoagulant doses. Monitor therapy

Thrombolytic Agents: May enhance the anticoagulant effect of Anticoagulants. Management: See full drug monograph for guidelines for the use of alteplase for acute ischemic stroke during treatment with oral anticoagulants. Monitor therapy

Tibolone: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Tipranavir: May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy

Urokinase: May enhance the anticoagulant effect of Anticoagulants. Avoid combination

Vitamin E (Systemic): May enhance the anticoagulant effect of Anticoagulants. Monitor therapy

Vitamin K Antagonists (eg, warfarin): Anticoagulants may enhance the anticoagulant effect of Vitamin K Antagonists. Monitor therapy

Vorapaxar: May enhance the adverse/toxic effect of Anticoagulants. More specifically, this combination is expected to increase the risk of bleeding. Avoid combination

Test Interactions

Prolongs activated partial thromboplastin time (aPTT), HepTest, and Russell viper venom time

Adverse Reactions

>10%: Hematologic & oncologic: Hemorrhage (any bleeding: 5% to 28%)

1% to 10%:

Central nervous system: Dizziness (2%), insomnia (2%), anxiety (1%), depression (1%), fatigue (1%), syncope (1%)

Dermatologic: Wound secretion (3%), pruritus (2%), skin blister (1%)

Gastrointestinal: Abdominal pain (3%), dyspepsia (1%), toothache (1%)

Genitourinary: Urinary tract infection (1%)

Hematologic & oncologic: Major hemorrhage (≤1%)

Hepatic: Increased serum transaminases (>3 x ULN: 2% [Watkins 2011])

Neuromuscular & skeletal: Back pain (3%), limb pain (2%), osteoarthritis (2%), muscle spasm (1%)

Respiratory: Oropharyngeal pain (1%), sinusitis (1%)

<1%, postmarketing, and/or case reports: Agranulocytosis, anaphylactic shock, anaphylaxis, angioedema, cerebral hemorrhage, cholestasis, epidural hematoma, gastrointestinal hemorrhage, hemiparesis, hemophthalmos, hepatitis, hepatic injury (Liakoni 2014), hypersensitivity reaction, intra-articular bleeding, intracranial hemorrhage, jaundice, retroperitoneal hemorrhage, Stevens-Johnson syndrome, subdural hematoma, thrombocytopenia (<100,000/mm3 or <50% baseline)

ALERT: U.S. Boxed Warning

Premature discontinuation increases the risk of thrombotic events:

Premature discontinuation of any oral anticoagulant, including rivaroxaban, increases the risk of thrombotic events. If anticoagulation with rivaroxaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant.

Spinal/Epidural hematomas:

Epidural or spinal hematomas have occurred in patients treated with rivaroxaban who are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include use of indwelling epidural catheters; concomitant use of other drugs that affect hemostasis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, or other anticoagulants; a history of traumatic or repeated epidural or spinal punctures; or a history of spinal deformity or spinal surgery. The optimal timing between the administration of rivaroxaban and neuraxial procedures is not known.

Monitor patients frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary.

Consider the benefits and risks before neuraxial intervention in patients who are anticoagulated or are to be anticoagulated for thromboprophylaxis.

Warnings/Precautions

Concerns related to adverse effects:

• Bleeding: The most common complication is bleeding; major hemorrhages (eg, intracranial, GI, retinal, epidural hematoma, adrenal bleeding) have been reported. Certain patients are at increased risk of bleeding; risk factors include bacterial endocarditis, congenital or acquired bleeding disorders, vascular retinopathy, thrombocytopenia, recent puncture of large vessels or organ biopsy, stroke, intracerebral surgery, or other neuraxial procedure, severe uncontrolled hypertension, renal impairment, recent major surgery, recent major bleeding (intracranial, GI, intraocular, or pulmonary), concomitant use of drugs that affect hemostasis, and advanced age. Monitor for signs and symptoms of bleeding (weakness, dizziness, unexplained edema). Prompt clinical evaluation is warranted with any unexplained decrease in hemoglobin or blood pressure. Andexanet alfa is available for reversal of rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding. Rivaroxaban is highly protein-bound, therefore, hemodialysis is ineffective. Protamine sulfate and vitamin K are not expected to affect the anticoagulant activity of rivaroxaban. Depending on the bleeding severity, activated oral charcoal should be considered if ingestion occurred within 1 to 2 hours of presentation. The following alternative options may also be considered depending on specific clinical scenario: 4-factor unactivated prothrombin concentrate (PCC) (eg, Kcentra) or 4-factor activated prothrombin complex concentrate (aPCC) (eg, FEIBA). Some studies and case reports have shown moderate success in correcting coagulation tests with some of these agents; however, correction of coagulation tests does not imply reversal of the anticoagulation effect of the medication (AHA/ASA [Hemphill 2015; EHRA [Heidbuchel 2015]; NCS/SCCM [Frontera 2016]).

• Thromboembolic events: [US Boxed Warning]: As with any oral anticoagulant in the absence of adequate alternative anticoagulation, an increased risk of thrombotic events (including stroke) may occur with premature discontinuation of rivaroxaban. Consider the addition of alternative anticoagulant therapy when discontinuing rivaroxaban for reasons other than pathological bleeding or completion of a course of therapy. An increased rate of stroke was observed during the transition from rivaroxaban to warfarin in clinical trials in atrial fibrillation patients. In a post-hoc analysis of the ROCKET AF trial, patients who temporarily (>3 days) or permanently discontinued anticoagulation, the risk of stroke or non-CNS embolism was similar with rivaroxaban as compared to warfarin (Patel 2013). In patients with nonvalvular atrial fibrillation who had an acute ischemic stroke while receiving a DOAC (eg, rivaroxaban), guidelines generally support withholding oral anticoagulation until 4 to 14 days after the onset of neurological symptoms (time frame may vary with shorter times for transient ischemic attack or small, non-disabling stroke and longer times for moderate-to-severe stroke) (AHA/ASA [Kernan 2014]; AHA/ASA [Powers 2018]).

Disease-related concerns:

• Hepatic impairment: Avoid use in patients with moderate to severe hepatic impairment (Child-Pugh classes B and C) or in patients with any hepatic disease associated with coagulopathy.

• Renal impairment: Use with caution in patients with moderate renal impairment (CrCl 30 to 50 mL/minute) when used for VTE prophylaxis in total hip or knee arthroplasty, including patients receiving concomitant drug therapy that may increase rivaroxaban systemic exposure and those with deteriorating renal function. Monitor for any signs or symptoms of blood loss. Avoid use in patients with CrCl <30 mL/minute in DVT/PE and VTE prophylaxis for total hip or knee arthroplasty. Discontinue use in patients who develop acute renal failure. Some experts do not recommend the use of rivaroxaban in patients with ESRD requiring hemodialysis; if used, do so with extreme caution while closely monitoring for bleeding (Chan 2016). According to the AHA/ACC/HRS, may consider dose reduction in patients with nonvalvular AF and moderate to severe chronic kidney disease (CKD), although safety and efficacy of this approach has not been established; rivaroxaban is not recommended for patients with AF and end-stage CKD or on hemodialysis (AHA/ACC/HRS [January 2014]).

• Valvular disease: Safety and efficacy have not been established in patients with prosthetic heart valves or significant rheumatic heart disease (eg, mitral stenosis); use is not recommended. Nonvalvular atrial fibrillation is defined as atrial fibrillation that occurs in the absence of rheumatic mitral valve disease, mitral valve repair, or prosthetic heart valve (AHA/ACC/HRS [January 2014]).

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Elderly: Use with caution in the elderly. Elderly patients exhibit higher rivaroxaban concentrations compared to younger patients due primarily to reduced clearance. Overall, efficacy of rivaroxaban in the elderly (≥65 years of age) was similar to that of patients <65 years of age. Both thrombotic and bleeding events were higher in the elderly; however, the risk to benefit profile was favorable among all age groups.

Dosage form specific issues:

• Lactose intolerance: May contains lactose; use is not recommended in patients with lactose or galactose intolerance (eg, Lapp lactase deficiency, glucose-galactose malabsorption).

Other warnings/precautions:

• Spinal or epidural hematoma: [US Boxed Warning]: Spinal or epidural hematomas may occur with neuraxial anesthesia (epidural or spinal anesthesia) or spinal puncture in patients who are anticoagulated; may result in long-term or permanent paralysis. The risk of spinal/epidural hematoma is increased with the use of indwelling epidural catheters, concomitant administration of other drugs that affect hemostasis (eg, NSAIDS, platelet inhibitors, other anticoagulants), in patients with a history of traumatic or repeated epidural or spinal punctures, or a history of spinal deformity or spinal surgery. Monitor for signs of neurologic impairment (eg, midline back pain, numbness/weakness of legs, bowel/bladder dysfunction); prompt diagnosis and treatment are necessary. In patients who are anticoagulated or pharmacologic thromboprophylaxis is anticipated, assess risks versus benefits prior to neuraxial interventions. The optimal timing between the administration of rivaroxaban and neuraxial procedures is not known. Placement or removal of an epidural catheter or lumbar puncture is best performed when the anticoagulant effect of rivaroxaban is low. European guidelines recommend waiting at least 22 to 26 hours following the last rivaroxaban dose when using prophylactic dosing (eg, 10 mg once daily) before catheter placement or lumbar puncture (Gogarten 2010). When higher doses are used (eg, 20 mg once daily), some suggest avoidance of neuraxial procedures for at least 48 hours (Rosencher 2013). In patients who have received neuraxial anesthesia concurrently with rivaroxaban (usually in patients undergoing knee or hip arthroplasty), avoid removal of epidural catheter for at least 18 hours following the last rivaroxaban dose; avoid rivaroxaban administration for at least 6 hours following epidural catheter removal; if traumatic puncture occurs, avoid rivaroxaban administration for at least 24 hours. In addition to these and other clinical variables, consider renal function and the age of the patient (elderly patients exhibit a prolonged rivaroxaban half-life [11 to 13 hours]) (Kubitza 2010; Rosencher 2013). The Canadian labeling recommends avoiding doses >10 mg in patients with a postoperative indwelling epidural catheter.

Monitoring Parameters

CBC with differential; renal function prior to initiation, when clinically indicated, and at least annually (AHA/ACC/HRS [January 2014]); hepatic function.

Routine coagulation testing is not required or necessary for direct oral anticoagulants (DOACs). There are currently no FDA-approved assays or calibration reagents available.

In clinical situations when assessment of the anticoagulant effect is useful (eg, acute care, periprocedural settings), evaluating a recent creatinine clearance and time since the last dose was ingested is usually sufficient for guiding clinical decisions. Most commonly used coagulation tests (PT, INR, aPTT) cannot definitively exclude the presence of clinically relevant serum concentrations. A prolonged PT suggests clinically relevant serum concentrations are present, but normal PT and aPTT values using standard reagents cannot rule out the presence of rivaroxaban. Highly sensitive reagents for PT testing may be able to exclude the presence of rivaroxaban. If available, the preferred test to rule out clinically significant serum concentrations and quantify anticoagulant effect is anti-factor Xa activity calibrated specifically for rivaroxaban (undetectable anti-Xa activity likely excludes clinically relevant drug concentrations). An anti-factor Xa assay calibrated for low molecular weight heparin can rule out clinically relevant drug concentrations, but is not useful for quantification (ACC [Tomaselli 2017]; AHA [Raval 2017]).

Pregnancy Considerations

Based on ex vivo data, rivaroxaban crosses the placenta (Bapat 2015). Bleeding may occur in the fetus or neonate.

Information related to the use of rivaroxaban during pregnancy (Hoeltzenbein 2015; Königsbrügge 2014; Myers 2016) and postpartum (Rudd 2015) is limited. Use may increase the risk of pregnancy related hemorrhage. Clinicians should note that the anticoagulant effect cannot be easily monitored or readily reversed. Prompt clinical evaluation is warranted with any unexplained decrease in hemoglobin, hematocrit, or blood pressure, or fetal distress. Data are insufficient to evaluate the safety of oral factor Xa inhibitors during pregnancy; use during pregnancy should be avoided (Guyatt 2012).

Pregnancy planning should be discussed if use is needed in females of reproductive potential.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Have patient report immediately to prescriber signs of bleeding (vomiting blood or vomit that looks like coffee grounds, coughing up blood, blood in the urine, black, red, or tarry stools, bleeding from the gums, abnormal vaginal bleeding, bruises without a reason or that get bigger, or any bleeding that is very bad or that you cannot stop), severe dizziness, syncope, paresthesia, loss of strength or energy, a fall hitting head, illogical thinking, severe headache, wound site pain, edema, or new drainage (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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