How to restart rivaroxaban (Xarelto) treatment after a patient has stopped the loading dose?

Restarting Rivaroxaban After Interruption of Loading Dose

When restarting rivaroxaban after interruption of the loading dose, resume with the standard treatment dose of 20 mg once daily, or 15 mg once daily if CrCl is 30-50 mL/min. 1

Assessment Before Restarting

Before restarting rivaroxaban, consider:

• Time since last dose was taken
• Reason for interruption (bleeding, procedure, non-adherence)
• Current bleeding risk
• Thrombotic risk based on original indication

Restarting Protocol Based on Interruption Scenario

1. After Brief Interruption (≤24 hours)

• Simply resume the regular dosing schedule
• For once-daily regimen: Take the missed dose as soon as remembered on the same day 1
• Do not double the dose to make up for a missed dose 1

2. After Procedure or Surgery

• For low bleeding risk procedures: Resume rivaroxaban 24 hours after the procedure 2
• For high bleeding risk procedures: Resume rivaroxaban 48-72 hours after the procedure 2
• Consider starting with a reduced dose (10 mg once daily) for 2-3 days after high bleeding risk procedures before increasing to the full dose 2

3. After Bleeding Event

• Assess if bleeding is controlled and source identified
• For non-major bleeding: Resume rivaroxaban once bleeding is controlled 2
• For major bleeding: Consider delaying restart of anticoagulation until patient is stable and bleeding risk is acceptable 2

Special Considerations

• Rapid Onset of Action: Remember that rivaroxaban reaches therapeutic anticoagulation within 2-4 hours of administration 2
• Half-life: Rivaroxaban has a half-life of 8-9 hours in patients with normal renal function 2
• Renal Function: Adjust dose based on creatinine clearance:
  • CrCl >50 mL/min: 20 mg once daily
  • CrCl 30-50 mL/min: 15 mg once daily
  • CrCl <30 mL/min: Not recommended

Practical Tips

• Rivaroxaban 15-20 mg doses should be taken with food to enhance absorption
• For patients unable to swallow tablets, rivaroxaban can be crushed and mixed with applesauce or suspended in water for administration via nasogastric tube 1
• If transitioning from parenteral anticoagulants to rivaroxaban, start rivaroxaban 0-2 hours before the next scheduled dose of the parenteral agent 1
• For continuous infusion of unfractionated heparin, stop the infusion and start rivaroxaban at the same time 1

Common Pitfalls to Avoid

1. Dosing errors: Ensure the correct dose is prescribed and dispensed. A case report documented a serious error where 150 mg was dispensed instead of 15 mg 3

2. Inadequate bridging: Unlike warfarin, rivaroxaban has a rapid onset of action and does not require bridging with heparin when restarting

3. Inappropriate timing: Restarting too soon after procedures with high bleeding risk can lead to hemorrhagic complications

4. Failure to adjust for renal function: Always reassess renal function before restarting, especially in elderly patients or those with fluctuating renal function

By following these guidelines, clinicians can safely restart rivaroxaban therapy after interruption of the loading dose while minimizing risks of both thrombosis and bleeding.