When should a patient be switched from Eliquis (apixaban) to Xarelto (rivaroxaban) due to intolerance?

Switching from Eliquis (Apixaban) to Xarelto (Rivaroxaban) Due to Intolerance

A patient should be switched from Eliquis to Xarelto when experiencing specific intolerance issues such as gastrointestinal side effects, unexplained bleeding complications despite appropriate dosing, or difficulty with twice-daily dosing adherence.

Indicators of Apixaban Intolerance

Clinical Signs of Intolerance

• Bleeding complications despite appropriate dosing adjustments
• Gastrointestinal symptoms (nausea, dyspepsia, abdominal pain) that persist despite mitigation strategies
• Skin reactions or hypersensitivity manifestations
• Adherence challenges with twice-daily dosing regimen of apixaban

Specific Scenarios Warranting Switch

1. Dosing Adherence Issues

   • Patients struggling with twice-daily dosing of apixaban may benefit from rivaroxaban's once-daily regimen 1
   • Particularly relevant for patients with cognitive impairment or complex medication schedules

2. Gastrointestinal Tolerance

   • Persistent GI symptoms with apixaban despite taking with food
   • Note: If switching due to GI symptoms, monitor closely as rivaroxaban has higher rates of GI bleeding (21.9 vs 12.9 per 1000 person-years) 2

3. Medication Interactions

   • Different drug interaction profiles between the medications may favor switching
   • Rivaroxaban has different CYP3A4 and P-glycoprotein interaction patterns 1

4. Absorption Considerations

   • Apixaban can be taken without regard to food
   • Rivaroxaban requires food for optimal absorption 1
   • Patients with altered GI anatomy might tolerate one agent better than the other

Clinical Decision Algorithm

1. Confirm true intolerance rather than improper use or dosing:

   • Verify patient is taking correct dose based on age, weight, and renal function
   • Rule out other causes of symptoms or bleeding (concurrent medications, underlying conditions)

2. Assess specific intolerance pattern:

   • Bleeding complications: Location, severity, relationship to dosing
   • GI symptoms: Timing relative to medication, severity, impact on quality of life
   • Adherence issues: Missed doses, confusion about regimen

3. Consider comparative safety profiles:

   • Apixaban has lower rates of major bleeding compared to rivaroxaban (HR 0.58,95% CI 0.52-0.66) 2
   • Rivaroxaban has higher rates of nonfatal extracranial bleeding (39.7 vs 18.5 per 1000 person-years) 3
   • Apixaban demonstrates lower risk of both ischemic events and hemorrhagic events 2

4. Evaluate patient-specific factors:

   • Renal function: Both medications require dose adjustments for impaired renal function
   • Age and fall risk: Consider the higher bleeding risk with rivaroxaban
   • Concomitant medications: Check for potential interactions with either agent

Switching Process

1. Timing of switch:

   • For patients with normal renal function, discontinue apixaban and start rivaroxaban at the time of next scheduled apixaban dose
   • No overlap period is required due to rapid onset of action of both medications

2. Dosing considerations:

   • Standard rivaroxaban dose for atrial fibrillation: 20 mg once daily with food
   • Reduced dose (15 mg once daily) for CrCl 15-50 mL/min 4

3. Monitoring after switch:

   • Assess for resolution of previous intolerance symptoms
   • Monitor for new side effects or bleeding complications
   • Check renal function periodically

Important Caveats

• Comparative effectiveness: Recent studies show apixaban may be more effective than rivaroxaban for stroke prevention (6.6 vs 8.0 events per 1000 person-years) with lower bleeding risk 2
• No specific antidote for rivaroxaban is widely available (similar to apixaban)
• Food requirement: Unlike apixaban, rivaroxaban must be taken with food for optimal absorption 1
• Once-daily dosing of rivaroxaban means missing a dose results in longer periods without anticoagulation coverage

Contraindications to Switching

• Mechanical heart valves or significant mitral stenosis: Neither apixaban nor rivaroxaban is appropriate 1
• Severe renal impairment (CrCl <15 mL/min): Both medications are contraindicated 4
• Active major bleeding: Resolve bleeding before initiating any anticoagulant
• Pregnancy or breastfeeding: DOACs are not recommended 4

Remember that while switching between DOACs is sometimes necessary due to intolerance, apixaban generally demonstrates a more favorable safety profile with lower rates of major bleeding and better effectiveness in stroke prevention compared to rivaroxaban based on recent comparative studies 3, 2.