What is a good substitute for Rivaroxaban (Xarelto)?

From the Guidelines

Apixaban (Eliquis) is a good substitute for Xarelto (rivaroxaban), as both are direct oral anticoagulants (DOACs) used to prevent blood clots, with apixaban being recommended over warfarin in NOAC-eligible patients with AF, according to the 2019 AHA/ACC/HRS guideline 1. When considering a substitute for Rivaroxaban, several factors must be taken into account, including the patient's medical condition, kidney function, and other medications they are taking.

• The appropriate substitute depends on these factors, with options including dabigatran (Pradaxa) and edoxaban (Savaysa), depending on the specific condition being treated.
• Dosing varies by medication and condition - for example, apixaban is typically taken twice daily (2.5mg or 5mg), while Xarelto is usually once daily.
• These medications work similarly by inhibiting specific clotting factors in the blood, though they target different points in the coagulation cascade.
• Before switching medications, it's essential to consult with your healthcare provider, as an abrupt change can increase bleeding or clotting risks, and the doctor will need to determine the appropriate dosage and timing for transitioning between medications to maintain effective anticoagulation, as supported by the 2014 AHA/ACC/HRS guideline 1.
• The selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent, and renal function and hepatic function should be evaluated before initiation of a NOAC and should be reevaluated at least annually, as recommended in the 2019 AHA/ACC/HRS guideline 1.

From the Research

Alternatives to Rivaroxaban (Xarelto)

• Apixaban (Eliquis) is a direct oral factor Xa-inhibitor that has been shown to be non-inferior or superior compared with vitamin K antagonists or low-molecular weight heparins 2
• Edoxaban (Lixiana) is another direct oral factor Xa-inhibitor that is registered in Japan for prophylaxis against thrombosis after major orthopaedic surgery 2
• Dabigatran is a direct thrombin inhibitor that is increasingly being used in clinical practice as an alternative to warfarin 3

Comparison of Alternatives

• Apixaban and dabigatran have been compared to warfarin in patients with nonvalvular atrial fibrillation, with results showing no significant difference in the risk of stroke or systemic embolism, but a lower risk of intracranial bleeding with the new oral anticoagulants (NOACs) 4
• Rivaroxaban has been shown to be associated with reduced stroke or systemic embolism in frail nonvalvular atrial fibrillation patients, without significantly altering major bleeding risk 5
• In patients with nonvalvular atrial fibrillation and previous stroke or transient ischemic attack, rivaroxaban reduced the combined end point of ischemic stroke or intracranial hemorrhage without an effect on major bleeding 6

Key Characteristics of Alternatives

• All NOACs, including apixaban, dabigatran, and rivaroxaban, are more convenient than warfarin, do not require laboratory monitoring, and have limited drug and food interactions 3
• However, they also have shortcomings, such as dependence on renal clearance and lack of a specific antidote 2