How should a patient be switched from rivaroxaban (Xarelto) to apixaban (Eliquis)?

Switching from Rivaroxaban to Apixaban

Discontinue rivaroxaban and start apixaban at the time of the next scheduled rivaroxaban dose—no bridging or overlap is required. 1

Practical Switching Protocol

The FDA-approved apixaban label provides clear guidance for this transition 1:

• Stop rivaroxaban completely
• Begin apixaban at the exact time when the next rivaroxaban dose would have been due
• No washout period needed
• No parenteral anticoagulation bridging required

Dosing Considerations for Apixaban

Once you switch, determine the appropriate apixaban dose based on the indication:

For Atrial Fibrillation:

• Standard dose: 5 mg twice daily
• Reduced dose: 2.5 mg twice daily if the patient has at least 2 of the following:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 1

For VTE Treatment:

• Initial 7 days: 10 mg twice daily
• After 7 days: 5 mg twice daily 1

For VTE Secondary Prevention:

• 2.5 mg twice daily (after completing at least 6 months of treatment) 1

Clinical Context: Why This Switch Matters

Real-world evidence strongly supports this switch direction. Switching from rivaroxaban to apixaban is associated with lower major bleeding risk (HR 0.49-0.65) compared to continuing rivaroxaban 2, 3. Conversely, switching from apixaban to rivaroxaban increases both bleeding (HR 1.69-1.80) and stroke/systemic embolism risk (HR 1.99) 2, 3.

Key Safety Points

• Both drugs are factor Xa inhibitors with similar half-lives (rivaroxaban 5-9 hours, apixaban 12 hours), making direct switching safe without overlap 4
• No INR monitoring needed during the transition (unlike warfarin switches) 1
• Apixaban demonstrates more predictable pharmacokinetics with food-independent absorption, which may explain its superior safety profile 5

Common Pitfalls to Avoid

1. Do NOT overlap the medications—this creates unnecessary bleeding risk from anticoagulant stacking
2. Do NOT use bridging anticoagulation—direct oral anticoagulants achieve therapeutic levels rapidly
3. Do NOT forget dose adjustments—verify the patient meets criteria for dose reduction if applicable
4. Do NOT assume the same dose—rivaroxaban 20 mg daily does not equal apixaban 5 mg twice daily; use indication-specific dosing

Special Circumstances

If the patient has renal impairment:

• Apixaban: No dose adjustment needed for CrCl >15 mL/min (use dose-reduction criteria above)
• This is advantageous compared to rivaroxaban, which requires dose reduction at CrCl 15-50 mL/min 4

If the patient is on strong CYP3A4 and P-gp inhibitors (ketoconazole, itraconazole, ritonavir):

• Reduce apixaban 5 mg twice daily to 2.5 mg twice daily
• Avoid apixaban if already on 2.5 mg twice daily 1

If switching due to bleeding event:

• The evidence supports this switch—rivaroxaban-to-apixaban switching after bleeding shows 35-51% lower subsequent major bleeding risk 2, 3