Xarelto Explained: 10 Must-Knows About This Life-Saving Drug
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on May 8, 2021.
1. Xarelto: It's Not Just a Tongue-Twister
Xarelto (pronounced zah-REL-toe) is a drug that may be easier to understand than pronounce. And for many, it's a life-saving drug.
- Xarelto is used to treat or prevent a type of blood clot called a deep vein thrombosis (DVT), which can lead to a lung clot (pulmonary embolism or PE). DVTs can start in the lower leg, thigh, pelvis, or arm. A clot can also occur after surgeries, like a knee or hip replacement.
- Xarelto is used in people with non-valvular atrial fibrillation (a heart rhythm disorder) to lower the risk of a stroke caused by a blood clot.
- Xarelto is also used with aspirin to lower the risk of a stroke, heart attack, or other major heart problems in people with coronary artery disease (decreased blood flow to the heart) or peripheral artery disease (decreased blood flow to the limbs).
- It was FDA-approved in Oct. 2019 for prevention of blood clots in acutely ill medical patients at risk for a blood clot (but not at high risk of bleeding).
2. How Does Xarelto Work?
Xarelto belongs to a class of drugs known as Factor Xa inhibitors. Factor Xa inhibitors are a type of anticoagulant that blocks the activity of clotting factor Xa (a protein in the blood that helps to stop bleeding).
By blocking Xa, Xarelto helps to keep blood clots from developing or getting worse. Factor Xa activates the blood protein prothrombin to thrombin, which triggers the final actions that help to form clots.
Another fun fact: notice that Xarelto begins with "Xa", and that's an easy way to remember how it works.
Other Factor Xa inhibitors that work like Xarelto include:
However, the newer anticoagulants are costly compared to warfarin, and may not be the right drugs for everyone. Xarelto may cause you to bleed more easily, and this is important to remember during your therapy.
3. Goodbye to Routine Blood Work
Maybe you've used the blood thinner warfarin - now or in the past. For many, many years, warfarin was the blood thinner of choice.
However, for some patients, warfarin can be cumbersome to use.
- It requires regular trips to the lab for blood work to check the dose.
- Food interactions that can lower the effectiveness of warfarin are a concern too. Healthy foods high in vitamin K, such as kale, spinach, turnip greens, and green leaf lettuce, can cause interactions. It's important to maintain a consistent consumption of the foods you eat with vitamin K.
A big plus with Xarelto is that it does not require regular blood tests or have food restrictions. Studies have shown that blood levels remain constant with Xarelto for a more predictable effect to help prevent blood clots.
If you are on warfarin, do not stop it without your doctors advice; this could increase your risk for a stroke.
4. Cautious Use: Signs of Bleeding
The most common side effect with Xarelto is bleeding. You may bruise easily or take longer to stop bleeding from a minor cut.
Get medical help immediately if you have:
- Frequent nose bleeds or bleeding gums
- Heavy menstrual or vaginal bleeding
- Uncontrollable bleeding or unexpected bruising
- Red, pink or brown urine
- Bright red or black, tarry stools
- Coughing up blood or vomit looks like “coffee grounds”
- Headaches, dizzy or weak
- Pain, swelling
5. Drugs Interactions: Risky Business With Xarelto
It's important to know that if you take Xarelto with another blood-thinning medication, both drugs added together may increase your bleeding risk.
Examples of other drugs that may increase your bleeding risk include:
- Aspirin or aspirin-containing products
- Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
- Blood thinners like warfarin (Coumadin, Jantoven) and others
- Clopidogrel (Plavix)
- Any other medicine for blood clots
This is not a complete list of all possible drug interactions with Xarelto. Tell your doctor and pharmacist about all of the medicines you take, including prescription medications, over-the-counter treatments, vitamins and herbal products. Have a drug interaction review completed by a healthcare provider.
6. Xarelto: Other Drug Interactions
Xarelto drug interactions can occur with many other medicines, too.
It's important to tell your doctor if you take:
- itraconazole (Onmel, Sporanox)
- ritonavir (Norvir)
- lopinavir and ritonavir (Kaletra)
- indinavir (Crixivan)
- carbamazepine (Tegretol and others)
- phenytoin (Dilantin)
- rifampin (Rifadin)
- St. John’s wort (Hypericum perforatum)
This is not a complete list of drug interactions with Xarelto.
7. Andexxa: Antidote for Reversal of Factor Xa Inhibitors
Vitamin K is a quick reversal agent to help treat bleeding with the older anticoagulant warfarin. But it doesn't work for drugs like Xarelto.
Research found there were approximately 117,000 U.S. hospital admissions due to Factor Xa inhibitor-related bleeding and nearly 2,000 bleeding-related deaths per month. Andexxa (coagulation factor Xa [recombinant], inactivated-zhzo), from Portola Pharmaceuticals, is a Factor Xa inhibitor reversal agent approved in 2018.
- Andexxa is an altered form of the human Factor Xa molecule, a human enzyme that helps blood to clot and lowers the risk from serious bleeding from Xa inhibitors.
- Andexxa is the first antidote available for patients being treated with rivaroxaban (Xarelto) and apixaban (Eliquis), when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding.
- Andexxa received both U.S. Orphan Drug and FDA Breakthrough Therapy designations and was approved under the FDA's Accelerated Approval pathway.
How does Andexxa work?
Andexxa works by acting as a trap for oral and injectable Factor Xa inhibitors, binding to the drug to reverse the anticoagulant effect. In Phase III studies, Andexxa rapidly and significantly reversed anti-Factor Xa activity. The median decrease in anti-Factor Xa activity from baseline was 97% for rivaroxaban (Xarelto) and 92% for apixaban (Eliquis).
8. Food and Xarelto: Know Your Dose
How you take Xarelto in relation to eating may be important for you. Always check your prescription to determine if you should take Xarelto with or without food.
- The higher doses of Xarelto -- the 15 and 20 milligram (mg) tablets -- should be taken with food to increase the absorption of the medicine.
- If you are taking Xarelto for stroke prevention in atrial fibrillation, take your dose with the evening meal.
- If you are taking the 15 or 20 mg tablets for treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE), take your tablets with food at the same time each day as directed by your doctor.
- The lower 10 mg dose, used to prevent a DVT after knee or hip replacement surgery or for reduction in the risk of recurrence of DVT and PE (if you are still at risk) can be taken with or without food.
- For cardiovascular risk reduction due to coronary artery disease or peripheral artery disease, the dose is 2.5 mg twice daily, plus aspirin (75–100 mg) once daily, with or without food. This lowers the combined risk of stroke, heart attack or other cardiovascular death.
- To prevent venous thromboembolism (VTE) in acutely ill medical patients at risk of clotting but not at high risk of bleeding, the 10 mg dose can be taken with or without food.
9. Warnings and Tips for Xarelto
Certain groups need to pay attention to special warnings with Xarelto. Talk with your doctor about taking Xarelto if:
- You are pregnant or plan on becoming pregnant
- If you are breastfeeding or plan to breastfeed
- If you have kidney or liver disease; drug doses may need to be changed
Do not stop taking Xarelto on your own, as this may increase the risk for a serious or life-threatening blood clot. Speak to your doctor first if think you should stop Xarelto.
Be sure to keep up with your refills so you do not miss any doses. Refill your Xarelto prescription before it runs outs.
10. Get to Know Your Pharmacist
If you are using Xarelto, it's important to communicate regularly with your doctor and pharmacist about treatment, even though you are not having regular lab tests.
One study from a VA clinic setting demonstrated that patients were 80% more likely to take their drug correctly without missing doses if the pharmacist reviewed their therapy and educated them about the drug, compared to those who didn't receive such assistance.
Stopping Xarelto, missing a dose, or taking it incorrectly can greatly boost your risk of a stroke or clot in your lung, which can be deadly. Talk to your doctor before you change your Xarelto treatment in any way.
Finished: Xarelto Explained: 10 Must-Knows About This Life-Saving Drug
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- Vinogradova Y, Coupland C, Hill T, et al. Risks and benefits of direct oral anticoagulants versus warfarin in a real world setting: cohort study in primary care. BMJ 2018;362:k2505. Accessed May 8, 2021.
- Xarelto [package insert]. Titusville, NJ. Janssen Pharmaceuticals. March 2020. Accessed May 8, 2021.
- Newer Blood Thinners May Not Bring Higher Bleeding Risk. Drugs.com. Oct. 18, 2017. Accessed May 13, 2020.
- Adherence to blood thinner best with pharmacist management, researcher says. Stanford Medicine News. Accessed May 8, 2021 https://med.stanford.edu/news/all-news/2015/04/adherence-to-blood-thinner-best-with-pharmacist-management.html
- FDA Approves Portola Pharmaceuticals’ Andexxa, First and Only Antidote for the Reversal of Factor Xa Inhibitors. Press Release. Portola Pharmaceuticals. Drugs.com. Accessed May 8, 2021 at https://www.drugs.com/history/andexxa.html