How to transition from argatroban to Xarelto (rivaroxaban)?

From the Guidelines

To transition from argatroban to Xarelto (rivaroxaban), discontinue the argatroban infusion and immediately administer the first dose of Xarelto, typically starting at 15 mg twice daily with food for 21 days, followed by 20 mg once daily for continued treatment, as recommended by the most recent guidelines 1. When transitioning from argatroban to Xarelto, it is essential to consider the patient's renal function and indication for anticoagulation. According to the NCCN guidelines, version 2.2024, rivaroxaban is dosed at 15 mg twice daily for the first 21 days, followed by 20 mg daily with food 1.

Key Considerations

• The patient's INR should be below 2.0 while on argatroban, but this is not a requirement for transitioning to Xarelto, as Xarelto does not affect INR measurements.
• Argatroban has a short half-life, allowing Xarelto to take effect quickly after the transition.
• Direct oral anticoagulants like Xarelto provide immediate anticoagulation and do not require overlap with argatroban.
• Monitor the patient closely during this transition for any signs of thrombosis or bleeding.

Dosing Considerations

• For patients with creatinine clearance 15-50 mL/min, a reduced dose of Xarelto may be necessary, but the NCCN guidelines do not specify a reduced dose for this population 1.
• The French working group on perioperative hemostasis guidelines from 2015 provide additional information on DOAC dosing, but the NCCN guidelines are more recent and relevant to this transition 1.

Clinical Implications

• The transition from argatroban to Xarelto should be done carefully, considering the patient's individual needs and risk factors for thrombosis and bleeding.
• Close monitoring and follow-up are essential to ensure the patient's safety and efficacy of the transition.

From the FDA Drug Label

Switching from Anticoagulants other than Warfarin to XARELTO - For adult and pediatric patients currently receiving an anticoagulant other than warfarin, start XARELTO 0 to 2 hours prior to the next scheduled administration of the drug (e.g., low molecular weight heparin or non-warfarin oral anticoagulant) and omit administration of the other anticoagulant. The answer to transitioning from argatroban (an anticoagulant other than warfarin) to Xarelto (rivaroxaban) is to start XARELTO 0 to 2 hours prior to the next scheduled administration of argatroban and omit administration of argatroban 2.

From the Research

Transitioning from Argatroban to Xarelto (Rivaroxaban)

There are no direct research papers to assist in answering this question, as the provided studies focus on transitioning from argatroban to warfarin or using argatroban in patients with heparin-induced thrombocytopenia. However, some general information about argatroban and its use can be gathered from the studies:

• Argatroban is a direct synthetic thrombin inhibitor used for prophylaxis or treatment of thrombosis in heparin-induced thrombocytopenia (HIT) 3.
• The US FDA-recommended argatroban dose in HIT is 2 microg/kg/min, adjusted to achieve activated partial thromboplastin times (aPTTs) 1.5-3 times baseline (not >100 seconds) 3.
• Argatroban prolongs the International Normalized Ratio (INR), and published approaches for monitoring the argatroban-to-warfarin transition should be followed 3, 4.
• When transitioning from argatroban to another anticoagulant, careful monitoring of the patient's condition and adjustment of the new anticoagulant's dose may be necessary to prevent thrombotic or bleeding complications.

Key Considerations

Some key considerations when transitioning from one anticoagulant to another include:

• The mechanism of action of the new anticoagulant (in this case, Xarelto, a factor Xa inhibitor)
• The patient's renal and hepatic function, as these can affect the metabolism and elimination of the new anticoagulant
• The patient's risk of thrombotic and bleeding complications, which can guide the choice of anticoagulant and the dose used
• The need for careful monitoring of the patient's condition and adjustment of the new anticoagulant's dose as needed 3, 5.