What is the recommended dose of Xarelto (rivaroxaban) for treating blood clots, such as deep vein thrombosis (DVT) or pulmonary embolism (PE)?

Rivaroxaban Dosing for Blood Clots (DVT/PE)

For treating blood clots (DVT or PE), rivaroxaban should be dosed at 15 mg twice daily with food for the first 21 days, followed by 20 mg once daily with food for the remainder of treatment.

Initial Treatment Phase

The treatment of acute venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), with rivaroxaban follows a specific dosing schedule:

• First 3 weeks (21 days): 15 mg twice daily with food 1, 2
• After 21 days: 20 mg once daily with food 1, 2

This dosing regimen is based on evidence from the EINSTEIN trials, which demonstrated that rivaroxaban was non-inferior to standard therapy (low molecular weight heparin followed by vitamin K antagonists) for the treatment of DVT and PE 3, 4.

Key Considerations

Administration

• Rivaroxaban must be taken with food to maximize absorption 2
• For patients who cannot swallow tablets whole:
  • Tablets can be crushed and mixed with applesauce 2
  • For patients with NG tubes, tablets can be crushed and mixed with water 2

Duration of Treatment

• Provoked VTE (with transient risk factors): Minimum 3 months 1
• Unprovoked VTE or persistent risk factors: Extended or indefinite treatment 1
• Recurrent VTE: Indefinite treatment 1

Extended Secondary Prevention

After completing at least 6 months of initial treatment, patients who require continued anticoagulation may be considered for a reduced dose:

• 10 mg once daily (with or without food) 1
• This reduced dose has been shown to be effective for secondary prevention while potentially reducing bleeding risk 1, 5

Special Populations

Renal Function:

• Dose adjustment is not required for mild renal impairment
• For severe renal impairment (CrCl <30 mL/min), consider alternative anticoagulants 1

Hepatic Impairment:

• Avoid in patients with significant hepatic disease with coagulopathy

Clinical Evidence

The EINSTEIN PE trial enrolled 4,832 patients with acute symptomatic PE and demonstrated that rivaroxaban was non-inferior to standard therapy for preventing recurrent VTE (2.1% vs 1.8%; HR 1.12; 95% CI 0.75-1.68) 3. Importantly, rivaroxaban was associated with significantly less major bleeding compared to standard therapy (1.1% vs 2.2%; HR 0.49; 95% CI 0.31-0.79; p=0.003) 3.

Similarly, the EINSTEIN DVT trial showed non-inferiority for rivaroxaban compared to standard therapy for acute DVT treatment (2.1% vs 3.0%; HR 0.68; 95% CI 0.44-1.04) 4.

Practical Management Tips

• Missed doses: If a dose is missed, take it as soon as remembered on the same day; do not double the dose to make up for a missed dose 2
• Perioperative management: For procedures with moderate/high bleeding risk, discontinue rivaroxaban at least 48 hours prior; for low bleeding risk procedures, discontinue at least 24 hours prior 1
• Monitoring: Routine coagulation monitoring is not required 6
• Switching from parenteral anticoagulants: Start rivaroxaban 0-2 hours before the next scheduled dose of parenteral anticoagulant, or at the time of discontinuation for continuous infusion

Common Pitfalls to Avoid

1. Incorrect initial dosing: Using 20 mg once daily from the start instead of the required 15 mg twice daily for the first 21 days
2. Taking without food: Rivaroxaban absorption is significantly reduced when taken on an empty stomach
3. Inappropriate dose reduction: The 15 mg daily dose used for atrial fibrillation in renal impairment is not appropriate for VTE treatment
4. Premature discontinuation: Stopping treatment before completing the recommended duration increases risk of recurrent VTE

By following this dosing regimen, rivaroxaban provides effective and convenient treatment for DVT and PE without the need for routine laboratory monitoring or initial parenteral anticoagulation.