Rivaroxaban Dosing for DVT Prevention
For DVT prevention, rivaroxaban should be dosed at 10 mg once daily for patients undergoing major orthopedic surgery, with treatment duration of 35 days for hip replacement and 10-14 days for knee replacement. 1
Dosing Regimens by Clinical Scenario
Post-Orthopedic Surgery Prophylaxis
- Dose: 10 mg once daily
- Timing: Start 6-10 hours after surgery when hemostasis is established
- Duration:
- Total Hip Replacement: 35 days (5 weeks)
- Total Knee Replacement: 10-14 days (2 weeks)
Acute DVT/PE Treatment
- Initial treatment: 15 mg twice daily with food for first 21 days
- Maintenance: 20 mg once daily with food
Extended Prevention (Secondary Prevention)
- After ≥6 months of initial therapy: Either continue 20 mg daily or reduce to 10 mg daily
- Reduced dose option: 10 mg once daily (shown to be effective with potentially lower bleeding risk) 1
Special Populations and Considerations
Renal Impairment
- CrCl 30-49 mL/min: No dose adjustment needed for prophylaxis
- CrCl <30 mL/min: Use with caution
- CrCl <15 mL/min: Not recommended 1
Contraindications
- Severe renal failure (CrCl <15 mL/min)
- Hepatic disease with coagulopathy
- Concomitant use of strong CYP3A4 and P-glycoprotein inhibitors (e.g., azole-antimycotics, HIV protease inhibitors)
- Pregnancy and breastfeeding 1
Clinical Pearls and Pitfalls
Important Considerations
- Rivaroxaban should be taken with food to enhance absorption, particularly for the 15 mg and 20 mg doses
- No routine coagulation monitoring is required
- For perioperative management, rivaroxaban should be discontinued at least 24 hours before procedures with low bleeding risk and 48 hours before procedures with high bleeding risk 1
Common Pitfalls
- Underdosing: Using the prophylactic dose (10 mg) for treatment of acute DVT/PE
- Incorrect timing: Starting too early after surgery (before hemostasis is achieved)
- Duration errors: Not continuing prophylaxis for the full recommended duration based on surgery type
- Missing food requirement: Administering higher doses without food, which reduces absorption
Evidence Quality
The recommendations for rivaroxaban in DVT prophylaxis are supported by high-quality evidence from multiple phase III clinical trials. In orthopedic surgery patients, rivaroxaban 10 mg once daily demonstrated superior efficacy compared to enoxaparin for VTE prevention, without significant increases in major bleeding 2. For treatment of established DVT/PE, the EINSTEIN trials showed non-inferiority to standard enoxaparin-VKA therapy with similar or better safety profiles 3.
For extended treatment beyond 6 months, reduced-dose rivaroxaban (10 mg daily) has been shown to be effective for secondary prevention with potentially lower bleeding risk compared to full-dose therapy 1.