How to Transition from Eliquis 5 mg Twice Daily to Xarelto
Simply discontinue Eliquis and start Xarelto at the time of the next scheduled Eliquis dose—no bridging or overlap is needed. 1
Direct Switching Protocol
The FDA-approved Eliquis prescribing information provides clear guidance for this transition 1:
- Stop Eliquis at your regular dosing time
- Start Xarelto at the exact time you would have taken your next Eliquis dose
- No bridging anticoagulation (such as heparin or enoxaparin) is required during this transition
- No overlap period is necessary between the two medications
Appropriate Xarelto Dosing
The correct Xarelto dose depends on your indication 2:
For Atrial Fibrillation:
- Standard dose: 20 mg once daily with the evening meal
- Reduced dose: 15 mg once daily if creatinine clearance is 15-50 mL/min 3
For Venous Thromboembolism (VTE):
- Initial treatment (if within first 21 days): 15 mg twice daily with food for 21 days, then 20 mg once daily 2
- Maintenance treatment (after initial 21 days): 20 mg once daily with food 2
- Extended prevention (after 6+ months): Consider 10 mg once daily 2
Critical point: The VTE treatment dose (20 mg daily) is higher than the atrial fibrillation dose sometimes used in certain trials (15 mg), so ensure you're using the VTE-specific dosing if that's your indication 2.
Important Considerations
Take Xarelto with food: Unlike Eliquis, rivaroxaban absorption is significantly enhanced with food—the 10 mg and 20 mg doses should be taken with the largest meal of the day to ensure proper bioavailability 3. This is a key difference from Eliquis, which can be taken without regard to meals.
Renal function matters: Check your creatinine clearance before switching. If CrCl is 15-50 mL/min and you're being treated for atrial fibrillation, use 15 mg once daily instead of 20 mg 3. For VTE treatment with severe renal impairment (CrCl 15-30 mL/min), Xarelto should be avoided 3.
Timing is everything: The seamless transition without gaps is crucial to maintain continuous anticoagulation and prevent thrombotic events while avoiding excessive anticoagulation from overlap 1.
Common Pitfalls to Avoid
- Don't bridge: Adding heparin or enoxaparin during the switch increases bleeding risk without benefit 1
- Don't overlap: Taking both medications together, even briefly, significantly increases bleeding risk
- Don't skip the food requirement: Xarelto 15-20 mg doses have reduced absorption when taken fasting—this could lead to treatment failure 3
- Don't use atrial fibrillation dosing for VTE: The 15 mg dose studied in some AF trials is inadequate for VTE treatment, which requires 20 mg daily maintenance 2
Evidence Quality Note
While the FDA label provides clear switching instructions 1, recent real-world evidence suggests that switching between DOACs may carry risks. A 2025 study found that switching from warfarin to rivaroxaban was associated with increased composite outcomes compared to continuing warfarin, and switching carried temporary increased risk in the first 60 days 4. Another 2024 study showed that switching from apixaban to rivaroxaban was associated with higher stroke and bleeding risks compared to continuing apixaban 5. Therefore, ensure there is a compelling clinical reason for the switch rather than switching for convenience alone.