What is the regular dose of Xarelto (Rivaroxaban)?

Rivaroxaban (Xarelto) Dosing Guidelines

The standard dose of rivaroxaban (Xarelto) for patients with nonvalvular atrial fibrillation is 20 mg once daily with food, with a reduced dose of 15 mg once daily with food for patients with creatinine clearance ≤50 mL/min. 1, 2

Dosing Based on Clinical Indication

For Nonvalvular Atrial Fibrillation

• Standard dose: 20 mg once daily with food 1, 3
• Reduced dose: 15 mg once daily with food for patients with CrCl 15-50 mL/min 1, 3
• Avoid use in patients with CrCl <15 mL/min 1

For Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

• Initial treatment: 15 mg twice daily with food for 21 days 1, 2
• Maintenance dose: 20 mg once daily with food 1, 2
• Secondary prevention: After 6 months, may reduce to 10 mg once daily 2

For DVT Prophylaxis After Hip or Knee Replacement

• 10 mg once daily 1

Renal Function Considerations

Renal function significantly impacts rivaroxaban dosing:

• Normal to mild impairment (CrCl >50 mL/min): Standard dosing
• Moderate impairment (CrCl 15-50 mL/min): Reduced dose of 15 mg once daily for AF 3
• Severe impairment (CrCl <15 mL/min): Avoid use 1
• End-stage renal disease on dialysis: Limited data available, generally not recommended 1

Hepatic Function Considerations

• Avoid use in patients with moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment 1
• Avoid use in patients with any hepatic disease associated with coagulopathy 1

Administration Guidelines

• Rivaroxaban 15 mg and 20 mg doses must be taken with food to ensure adequate absorption 1
• For patients unable to swallow tablets, rivaroxaban tablets may be crushed and mixed with applesauce immediately before use 1
• If a dose is missed:
  • For once-daily dosing: Take the missed dose as soon as possible on the same day 1
  • Do not double the dose to make up for a missed dose 1

Clinical Evidence Supporting Dosing

The ROCKET AF trial demonstrated that rivaroxaban 20 mg once daily (15 mg for moderate renal impairment) was noninferior to warfarin for stroke prevention in nonvalvular AF 3, 4. The trial included higher-risk patients with a mean CHADS₂ score of 3.47 3.

Rivaroxaban showed similar rates of major bleeding compared to warfarin but with less fatal bleeding and less intracranial hemorrhage 3, 4.

Common Pitfalls in Rivaroxaban Dosing

1. Inappropriate underdosing: Research shows that rivaroxaban is frequently underdosed in clinical practice, with approximately 52% of patients receiving reduced doses without meeting criteria for dose reduction 5

2. Missing food requirement: The 15 mg and 20 mg doses must be taken with food to ensure proper absorption 1

3. Inadequate transition between anticoagulants: When switching from warfarin to rivaroxaban, start rivaroxaban when INR is ≤3.0 1

4. Use in contraindicated conditions: Rivaroxaban should not be used in patients with mechanical heart valves, valvular AF, or severe renal/hepatic impairment 6, 1

5. Discontinuation before procedures: Rivaroxaban should be stopped at least 24 hours before procedures to reduce bleeding risk 1

Remember that unlike warfarin, rivaroxaban does not require routine coagulation monitoring, which may improve medication adherence 4, 6. However, this also means there is no standard laboratory test to assess the anticoagulant effect in emergency situations.