Xarelto (Rivaroxaban) Dosing and Indications for Anticoagulation
Rivaroxaban (Xarelto) is recommended for several anticoagulation indications with specific dosing regimens based on the condition being treated and patient characteristics, particularly renal function. The medication offers the advantage of fixed dosing without routine coagulation monitoring requirements.
Indications and Dosing Regimens
Stroke Prevention in Non-valvular Atrial Fibrillation
- Standard dose: 20 mg once daily with evening meal 1
- Reduced dose: 15 mg once daily for patients with moderate renal impairment (CrCl 30-49 mL/min) 1, 2
Venous Thromboembolism (VTE) Treatment
- Initial treatment: 15 mg twice daily for first 3 weeks 1
- Maintenance treatment: 20 mg once daily after initial 3 weeks 1
VTE Prophylaxis After Major Orthopedic Surgery
Special Considerations
Renal Function
- Dose adjustment required for moderate renal impairment (CrCl 30-49 mL/min)
- Not recommended for patients with CrCl <15 mL/min 3
- For patients with CrCl 15-30 mL/min, use with caution 3
Perioperative Management
For elective procedures with bleeding risk:
- Low bleeding risk procedures: Discontinue rivaroxaban 24 hours before procedure 3
- High bleeding risk procedures: Discontinue rivaroxaban at least 3 days before procedure when CrCl >30 mL/min 1
- Very high bleeding risk procedures (e.g., neurosurgery, neuraxial anesthesia): Discontinue up to 5 days before procedure 1
Missed Dose Management
- For once-daily regimen: Take missed dose immediately on the same day when noticed 3
- For twice-daily regimen: Missed morning dose may be taken with evening dose; missed evening dose should only be taken the same evening 3
- Never double a dose to make up for a missed dose 3
Efficacy and Safety Profile
Rivaroxaban has demonstrated:
- Non-inferiority to warfarin for stroke prevention in non-valvular AF 1, 4
- Similar overall bleeding risk compared to warfarin 4
- Significantly lower rates of intracranial hemorrhage (0.5% vs. 0.7%) and fatal bleeding (0.2% vs. 0.5%) compared to warfarin 4
Important Contraindications
- Valvular AF
- Prosthetic heart valves (mechanical or bioprosthetic)
- Severe renal impairment (CrCl <15 mL/min)
- Active clinically significant bleeding
- Concurrent use with strong CYP3A4 and P-glycoprotein inhibitors 1
Switching Between Anticoagulants
From Warfarin to Rivaroxaban
- Discontinue warfarin and start rivaroxaban when INR is below 3.0 3
From Rivaroxaban to Warfarin
- For adult patients: Discontinue rivaroxaban and begin both parenteral anticoagulant and warfarin at the time the next rivaroxaban dose would have been taken 3
- For pediatric patients: Continue rivaroxaban for at least 2 days after first warfarin dose; continue co-administration until INR ≥2.0 3
Clinical Pearls
- Rivaroxaban 15 mg and 20 mg doses should be taken with food to maximize absorption 3
- No routine coagulation monitoring is required, unlike warfarin
- For patients unable to swallow tablets, rivaroxaban can be crushed and mixed with applesauce or suspended in water for nasogastric administration 3
- In patients with AF and moderate renal impairment, the reduced dose of 15 mg daily has shown consistent efficacy with the standard dose in patients with normal renal function 2
Rivaroxaban offers a convenient alternative to warfarin with fixed dosing, no routine monitoring requirements, and a favorable bleeding profile, particularly regarding intracranial hemorrhage.