What are the guidelines for administering Rivaroxaban (Xarelto) via a gastric tube (g-tube)?

From the Guidelines

Rivaroxaban can be administered through a gastric tube by crushing the tablet and suspending it in 50 mL of water, then administering the suspension through the gastric tube, immediately followed by enteral feeding for the 15 mg and 20 mg tablets. When administering rivaroxaban via a gastric tube, it is crucial to position the tube in the stomach to ensure proper absorption, as administration distal to the stomach can result in reduced absorption 1. The crushed tablets are stable in water for up to 4 hours, allowing for some flexibility in preparation and administration timing. Key considerations for gastric tube administration of rivaroxaban include:

• Using 50 mL of water to suspend the crushed tablet
• Administering the suspension immediately after preparation, or within 4 hours
• Following administration of the 15 mg and 20 mg tablets with enteral feeding
• Avoiding administration distal to the stomach to maintain bioavailability
• Ensuring the tube is positioned in the stomach for optimal absorption. It is also important to note that rivaroxaban has specific dosing and administration guidelines, and patients with severe renal impairment (CrCl <15 mL/min) should not receive rivaroxaban, while those with moderate renal impairment (CrCl 15-50 mL/min) should be closely monitored 1.

From the FDA Drug Label

Administration of XARELTO tablets via nasogastric (NG) tube or gastric feeding tube: After confirming gastric placement of the tube, XARELTO tablets (all strengths) may be crushed and suspended in 50 mL of water and administered via an NG tube or gastric feeding tube Since rivaroxaban absorption is dependent on the site of drug release, avoid administration of XARELTO distal to the stomach which can result in reduced absorption and thereby, reduced drug exposure. Administration of XARELTO suspension via NG tube or gastric feeding tube: XARELTO oral suspension may be given through NG or gastric feeding tube. After the administration, flush the feeding tube with water.

Rivaroxaban can be administered via a gastric tube. The tablets can be crushed and suspended in water, or the oral suspension can be used. It is essential to confirm gastric placement of the tube and avoid administration distal to the stomach to ensure proper absorption 2. After administration, the feeding tube should be flushed with water.

From the Research

Administration of Rivaroxaban via Gastric Tube

• The administration of rivaroxaban via a gastric tube is a topic of interest, particularly for patients who have difficulty swallowing whole tablets 3.
• A study published in 2014 investigated the relative bioavailability of crushed rivaroxaban tablets administered orally or via a nasogastric tube in healthy adults 3.
• The results showed that the relative bioavailability of rivaroxaban was similar between crushed oral and whole tablet administration, as well as between crushed nasogastric tube administration and whole tablet administration 3.
• The study also found that the crushed rivaroxaban tablet was stable and did not degrade significantly over a 4-hour period, with a recovery rate of >98.4% across all suspensions and time points 3.

Pharmacokinetics and Pharmacodynamics of Rivaroxaban

• Rivaroxaban is a direct inhibitor of activated coagulation factor X (FXa) with high peroral bioavailability and a rapid onset of action 4.
• The absorption of rivaroxaban is quick, reaching maximum plasma concentration 2-4 hours after administration, with a high bioavailability of 80-100% 4.
• The pharmacokinetic variability of rivaroxaban is considered moderate, with a coefficient of variation of 30-40% 4.

Monitoring of Rivaroxaban Therapy

• The prothrombin time (PT) and international normalized ratio (INR) can be used to monitor the therapeutic effect of rivaroxaban, although there is variability in the responsiveness of rivaroxaban to different thromboplastins 5.
• A rivaroxaban-adjusted normalized ratio (NR) can be used to reduce the differences in sensitivity among reagents and provide a more accurate assessment of rivaroxaban therapy 5.
• The use of a rivaroxaban-specific NR can minimize inter-thromboplastin variability and provide standardized prothrombin time results 5.

Clinical Applications of Rivaroxaban

• Rivaroxaban is used for the prevention and treatment of venous thromboembolism (VTE), as well as for the prevention of ischemic stroke and embolism in patients with nonvalvular atrial fibrillation (NVAF) 4, 6.
• The drug has been shown to be effective in reducing the risk of ischemic stroke and systemic embolism in patients with NVAF, with a lower risk of major bleeding compared to warfarin 6.