What is the recommended dose of Xarelto (rivaroxaban)?

Recommended Dosing of Rivaroxaban (Xarelto)

The recommended dose of rivaroxaban varies by indication, with 20 mg once daily being the standard dose for atrial fibrillation, which should be reduced to 15 mg once daily in patients with moderate renal impairment (CrCl 15-49 mL/min). 1

Indication-Specific Dosing

Atrial Fibrillation

• 20 mg once daily with food for patients with normal renal function or mild impairment (CrCl ≥50 mL/min) 1, 2
• 15 mg once daily with food for patients with moderate renal impairment (CrCl 15-49 mL/min) 1, 3

Venous Thromboembolism (VTE) Treatment

• Initial phase: 15 mg twice daily for 21 days 1
• Maintenance phase: 20 mg once daily for patients with normal renal function 1
• Maintenance phase: 15 mg once daily for patients with moderate renal impairment (CrCl 15-49 mL/min) 1

VTE Prophylaxis After Major Orthopedic Surgery

• 10 mg once daily 2
• Duration:
  • Total hip replacement: 35 days 2
  • Total knee replacement: 10-14 days 2

Dosing Considerations for Special Populations

Renal Impairment

• Normal or mild impairment (CrCl ≥50 mL/min): Standard dosing as per indication 1
• Moderate impairment (CrCl 15-49 mL/min): Dose reduction required for most indications 1, 3
• Severe impairment (CrCl <15 mL/min): Generally not recommended 4
• Hemodialysis patients: Limited data suggests 10 mg may provide similar exposure to 20 mg in healthy volunteers, but not FDA approved for this population 4

Elderly Patients

• No specific dose adjustment required based solely on age 5
• Consider renal function assessment as elderly patients often have reduced renal clearance 1

Perioperative Management

Low Bleeding Risk Surgery

• Last dose: 2 days before surgery (skip 1 dose) for patients with normal or mild renal impairment 2
• Last dose: 3 days before surgery (skip 2 doses) for patients with severe renal impairment 2

High Bleeding Risk Surgery

• Last dose: 3 days before surgery (skip 2 doses) for patients with normal or mild renal impairment 2
• Last dose: 4 days before surgery (skip 3 doses) for patients with severe renal impairment 2

Pharmacokinetic Properties

• Rapid onset of action (peak effect within 2-4 hours) 5
• Half-life: 7-11 hours in young adults, 11-13 hours in elderly patients 5
• High oral bioavailability (80-100%) for 10 mg dose 5
• Approximately one-third of active rivaroxaban is cleared by the kidneys 1

Important Considerations

• Rivaroxaban should be taken with food to enhance absorption, particularly for the 15 mg and 20 mg doses 1, 5
• Regular assessment of renal function is recommended, with more frequent monitoring (2-3 times per year) for patients with moderate renal impairment 1
• No routine coagulation monitoring is required 5
• Avoid concomitant use with strong inhibitors of both CYP3A4 and P-glycoprotein (e.g., most azole antimycotics and protease inhibitors) 5

Reversal Agent

• Andexanet alfa is available for reversal of rivaroxaban in life-threatening or uncontrolled bleeding situations 2
• For urgent procedures or life-threatening bleeding, 4-factor prothrombin complex concentrate may be used off-label 2