What are the considerations for switching from Eliquis (apixaban) to Xarelto (rivaroxaban) in a patient with deep venous thrombosis (DVT) on the left foot posterior knee, who is also taking Entresto (sacubitril/valsartan) for heart disease?

Switching from Apixaban to Rivaroxaban for DVT Treatment

When switching from Eliquis (apixaban) to Xarelto (rivaroxaban) for deep venous thrombosis, administer the first dose of rivaroxaban at the time the next dose of apixaban would have been due, with no overlap period required.

Considerations for Switching Between DOACs

Timing of Switch

• For patients on apixaban (typically dosed twice daily), initiate rivaroxaban (typically once daily) at the time the next scheduled dose of apixaban would have been due 1
• No overlap period is necessary as both medications are direct oral anticoagulants (DOACs) with similar mechanisms of action
• No bridging therapy with parenteral anticoagulants is required when switching between these two agents

Dosing Considerations

• For acute DVT treatment, rivaroxaban dosing is 15 mg twice daily for the first 21 days, followed by 20 mg once daily 2, 1
• If the patient has already completed the initial 21-day treatment phase with apixaban, start directly with rivaroxaban 20 mg once daily
• Take rivaroxaban with food to optimize absorption, particularly for the 15 mg and 20 mg doses 1

Special Considerations with Heart Disease

• For patients on Entresto (sacubitril/valsartan) for heart disease, no specific dose adjustments of rivaroxaban are required based on this medication alone
• However, assess renal function carefully as heart failure patients may have fluctuating renal function that could affect DOAC dosing
• If creatinine clearance is 15-50 mL/min, use rivaroxaban with caution 1
• If creatinine clearance is <15 mL/min, avoid rivaroxaban 1

Duration of Anticoagulation Therapy

The appropriate duration of anticoagulation therapy depends on whether the DVT was provoked or unprovoked:

• For DVT associated with a major transient risk factor: 3 months of therapy is recommended 2
• For DVT associated with a minor transient risk factor: 3 months of therapy is typically sufficient 2
• For unprovoked DVT or DVT with persistent risk factors: extended anticoagulation therapy is recommended 2

For extended therapy, the CHEST guidelines suggest using reduced-dose rivaroxaban (10 mg once daily) over full-dose rivaroxaban (20 mg once daily) 2.

Monitoring After Switch

• Monitor for signs of bleeding or thrombosis during the transition period
• No specific laboratory monitoring is required for either apixaban or rivaroxaban
• Reassess the need for continued anticoagulation at least annually 2
• Ensure patient understands the importance of medication adherence, particularly with rivaroxaban which is typically once daily (missing a dose could have more significant consequences than with twice-daily apixaban)

Potential Advantages of Rivaroxaban

• Once-daily dosing (after initial treatment phase) may improve adherence compared to twice-daily apixaban
• Rivaroxaban has been directly compared to aspirin for secondary prevention of VTE and demonstrated superiority 2
• The EINSTEIN trials demonstrated non-inferiority of rivaroxaban compared to standard therapy for DVT treatment 3

Potential Pitfalls and Cautions

• Ensure patient takes rivaroxaban with food for optimal absorption, particularly for the 15 mg and 20 mg doses 1
• Avoid abrupt discontinuation of either DOAC without appropriate alternative anticoagulation due to increased thrombotic risk 1
• For patients with GI malignancies, apixaban may have a more favorable bleeding profile than rivaroxaban 4
• If the patient has antiphospholipid syndrome, DOACs are generally not recommended; vitamin K antagonists are preferred 2

By following these guidelines, the transition from apixaban to rivaroxaban can be accomplished safely and effectively for patients with DVT who also have heart disease requiring Entresto therapy.