What medication to give instead of Xarelto (rivaroxaban) for a patient experiencing bleeding?

Management of Bleeding in Patients on Rivaroxaban (Xarelto)

For patients experiencing bleeding while on rivaroxaban (Xarelto), discontinue the medication and administer andexanet alfa as the preferred reversal agent, or prothrombin complex concentrate (PCC) if andexanet alfa is unavailable. 1

Initial Management of Bleeding on Rivaroxaban

Assessment of Bleeding Severity

• Determine if the bleeding is major by checking for: bleeding at a critical site, hemodynamic instability, or clinically overt bleeding with hemoglobin decrease ≥2 g/dL or requiring ≥2 units of red blood cells 1
• Identify if bleeding is at a critical site (intracranial, pericardial, intraocular, etc.) or life-threatening 1

Immediate Actions for Major Bleeding

1. Stop rivaroxaban immediately 1

2. Provide local therapy and manual compression where applicable 1

3. Administer specific reversal agent:

   • Andexanet alfa is the FDA-approved reversal agent for rivaroxaban-associated life-threatening or uncontrolled bleeding 1, 2
   • Dosing depends on timing of last rivaroxaban dose:
     • If taken ≥8 hours prior: low dose (400 mg IV bolus followed by 4 mg/min infusion for up to 120 minutes) 1
     • If taken <8 hours prior or timing unknown: high dose (800 mg IV bolus followed by 8 mg/min infusion for up to 120 minutes) 1

4. If andexanet alfa is unavailable:

   • Administer prothrombin complex concentrate (PCC) or activated PCC at 50 U/kg 1, 3
   • Consider activated charcoal for known recent ingestion (within 2-4 hours) 1

Alternative Anticoagulants After Bleeding on Rivaroxaban

Direct Thrombin Inhibitor Option

• Dabigatran (Pradaxa) may be considered as an alternative with a different mechanism of action (direct thrombin inhibitor vs. Factor Xa inhibitor) 1
• Advantage: Has specific reversal agent (idarucizumab) that is widely available 1
• Caution: Not recommended in severe renal failure due to its predominant renal elimination 1

Alternative Factor Xa Inhibitors

• Apixaban (Eliquis) may be considered as it has shown a favorable bleeding profile in clinical trials 3, 4
• Edoxaban (Lixiana/Savaysa) is another Factor Xa inhibitor option with potentially different pharmacokinetics 1

Traditional Anticoagulants

• Warfarin (Coumadin) can be considered when specific reversal is needed, as its effects can be reversed with vitamin K and PCC 4
• Low molecular weight heparin may be appropriate for short-term use while transitioning to another oral anticoagulant 1

Considerations for Restarting Anticoagulation

Timing of Anticoagulation Restart

• After major bleeding is controlled, assess if there is a clinical indication for continued anticoagulation 1
• Consider delaying restart if:
  • Bleeding occurred at a critical site
  • Patient is at high risk of rebleeding
  • Source of bleed has not been identified
  • Surgical procedures are planned 1

Risk Factor Modification Before Restarting

• Address modifiable bleeding risk factors:
  • Reduce alcohol consumption (heavy alcohol use increases bleeding risk 2.37-fold) 5
  • Control hypertension (uncontrolled hypertension increases risk 1.79-fold) 5
  • Discontinue or minimize use of antiplatelets, NSAIDs, or paracetamol when possible (increases risk 1.80-fold) 5

Special Considerations

Perioperative Management

• For elective procedures with high bleeding risk, discontinue rivaroxaban 3 days before the procedure if creatinine clearance is >30 mL/min 1
• For emergency surgery with life-threatening bleeding, use reversal protocol as outlined above 6

Common Pitfalls to Avoid

• Do not rely on INR or aPTT to assess rivaroxaban activity, as these tests do not correlate well with drug levels 4
• Do not administer vitamin K or fresh frozen plasma to reverse rivaroxaban, as they are ineffective 3, 4
• Do not restart anticoagulation too early after a major bleeding event, especially with intracranial hemorrhage 1
• Avoid prophylactic use of hemostatic blood products in the absence of active bleeding 6

By following this algorithmic approach to managing bleeding in patients on rivaroxaban, clinicians can effectively control hemorrhage while preparing for appropriate alternative anticoagulation when indicated.