What is the recommended treatment duration for acute first-time pulmonary embolism (PE) with Xarelto (rivaroxaban)?

From the Guidelines

For a first-time acute pulmonary embolism (PE), the recommended treatment duration with Xarelto (rivaroxaban) is at least 3 months, with the possibility of extended treatment depending on individual risk factors, as stated in the 2019 ESC guidelines 1.

Treatment Regimen

The treatment typically starts with 15 mg twice daily for the first 21 days, followed by 20 mg once daily.

• The total duration of treatment depends on risk factors and should be determined by a healthcare provider.
• For patients with first PE secondary to a major transient/reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months 1.
• Extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor, or with a persistent risk factor other than antiphospholipid antibody syndrome 1.

Important Considerations

• Patients should take Xarelto with food to improve absorption, especially the 15 mg and 20 mg doses.
• Patients should avoid missing doses and not stop the medication without medical consultation due to increased clot risk.
• Regular follow-up appointments are essential to monitor for bleeding complications, which are the main risk of treatment.

Reduced Dose Consideration

• If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of rivaroxaban (10 mg o.d.) should be considered after 6 months of therapeutic anticoagulation 1. This approach is based on the most recent and highest quality evidence available, prioritizing morbidity, mortality, and quality of life as the outcome.

From the Research

Treatment Duration for Acute First-Time Pulmonary Embolism (PE) with Xarelto (Rivaroxaban)

• The recommended treatment duration for acute first-time pulmonary embolism (PE) with Xarelto (rivaroxaban) is at least three months 2, 3, 4.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 3.
• Patients with a strong transient risk factor have a low risk of recurrence and anticoagulation can be discontinued after three months, while patients with strong persistent risk factor (such as active cancer) have a high risk of recurrence and thus should receive anticoagulant treatment of indefinite duration 3.
• Extended oral anticoagulation of indefinite duration should be considered for all patients with intermediate risk of recurrence, given the favourable safety profile of NOACs (especially if a reduced dosage of Apixaban or Rivaroxaban is initiated after at least six months of therapeutic anticoagulation) 3.
• Rivaroxaban allows a single-drug regimen even in patients with pulmonary embolism, and is effective for the extended treatment of VTE 5.

Dosage and Administration

• The dosage of rivaroxaban for the treatment of acute pulmonary embolism is 15 mg twice daily for 3 weeks, followed by 20 mg once daily 2.
• There was no decline in efficacy when the rivaroxaban dose was reduced to 10 mg once daily after 3 months of administration 6.