What questions should be asked to a patient with Deep Vein Thrombosis (DVT) before initiating Xarelto (rivaroxaban) therapy?

From the Guidelines

Before placing a patient with DVT on Xarelto (rivaroxaban), it is crucial to ask about their renal function, liver function, current medications, bleeding history, pregnancy status, and weight to minimize bleeding complications and ensure effective anticoagulation. According to the most recent and highest quality study 1, rivaroxaban is primarily eliminated via the kidneys, and thus, it should be avoided in patients with severe renal impairment and used with caution in those with moderate impairment. Specifically, inquire about kidney disease since Xarelto requires dose adjustment for CrCl <50 mL/min. Ask about liver disease as Xarelto is contraindicated in Child-Pugh B and C cirrhosis. Medication history is crucial to identify potential drug interactions, particularly with strong CYP3A4 and P-gp inhibitors/inducers. Question the patient about any history of abnormal bleeding, recent surgeries, or planned procedures. For women of childbearing age, confirm pregnancy status as Xarelto is contraindicated during pregnancy. Document the patient's weight since very low weight (<50 kg) may influence bleeding risk. Additionally, ask about compliance ability since Xarelto requires daily dosing and missed doses increase thrombosis risk. Some key points to consider when asking these questions include:

• Renal function: CrCl <50 mL/min requires dose adjustment, and severe renal impairment (CrCl <15 mL/min) is a contraindication 1
• Liver function: Xarelto is contraindicated in Child-Pugh B and C cirrhosis
• Medication history: identify potential drug interactions with strong CYP3A4 and P-gp inhibitors/inducers
• Bleeding history: question the patient about any history of abnormal bleeding, recent surgeries, or planned procedures
• Pregnancy status: Xarelto is contraindicated during pregnancy
• Weight: very low weight (<50 kg) may influence bleeding risk
• Compliance ability: Xarelto requires daily dosing, and missed doses increase thrombosis risk. These questions are essential because Xarelto has no readily available reversal agent in many settings, and careful patient selection helps minimize bleeding complications while ensuring effective anticoagulation, as supported by the NCCN panel's category 1 recommendations for apixaban and edoxaban in the DVT/PE setting 1.

From the FDA Drug Label

Before taking XARELTO, tell your doctor about all of your medical conditions, including if you or your child: have or ever had bleeding problems have liver or kidney problems have antiphospholipid syndrome (APS) If you take XARELTO and receive spinal anesthesia or have a spinal puncture, your doctor should watch you closely for symptoms of spinal or epidural blood clots. Tell your doctor right away if you have: back pain tingling numbness muscle weakness (especially in your legs and feet) loss of control of the bowels or bladder (incontinence)

The questions to ask a patient with DVT before placing them in XARELTO are:

• Do you have a history of bleeding problems?
• Do you have liver or kidney problems?
• Do you have antiphospholipid syndrome (APS)?
• Have you had any recent spinal anesthesia or spinal puncture?
• Do you have any symptoms of spinal or epidural blood clots, such as back pain, tingling, numbness, muscle weakness, or loss of control of the bowels or bladder? 2

From the Research

Patient Assessment Before Xarelto Administration

To ensure safe and effective treatment with Xarelto (rivaroxaban) for patients with Deep Vein Thrombosis (DVT), several key questions should be asked:

• What is the patient's renal function, specifically their creatinine clearance level, as rivaroxaban undergoes renal clearance and dose adjustments may be necessary for patients with severe renal impairment 3, 4, 5, 6?
• Are there any other medications the patient is taking that could interact with rivaroxaban, particularly those that are renally cleared, as these could affect rivaroxaban's efficacy and safety 4?
• Does the patient have a history of bleeding disorders or are they at a high risk of bleeding, as this could influence the decision to use rivaroxaban and the need for close monitoring 5, 7?
• What is the patient's cardiovascular disease status, as rivaroxaban is used for various cardiovascular indications and its use needs to be balanced with the risk of bleeding 5?

Renal Function Considerations

It is crucial to assess the patient's renal function before initiating Xarelto, as patients with severe renal impairment (creatinine clearance < 30 mL/min) may require dose adjustments or alternative anticoagulants 3, 6. However, recent studies suggest that rivaroxaban can be used in patients with severe renal impairment for the treatment and prevention of VTE without significant increases in major bleeding 6.

Medication Interactions and Bleeding Risk

Understanding the patient's current medication regimen and history of bleeding is vital to minimize potential drug interactions and bleeding risks associated with rivaroxaban 4, 7. Close monitoring may be necessary for patients with severe renal impairment or those taking medications that could affect rivaroxaban's pharmacokinetics 4, 5.