What is the recommended dosage of Rivaroxaban (Xarelto) for the treatment of Deep Vein Thrombosis (DVT)?

Rivaroxaban Dosing for Deep Vein Thrombosis Treatment

For the treatment of Deep Vein Thrombosis (DVT), rivaroxaban should be administered at 15 mg twice daily with food for the first 21 days, followed by 20 mg once daily with food for the remainder of the treatment period. 1, 2, 3

Initial Treatment Phase (First 21 Days)

• Rivaroxaban 15 mg should be taken twice daily with food for the first 21 days of treatment 1, 4
• No initial parenteral anticoagulation (such as heparin or enoxaparin) is required before starting rivaroxaban, making it a convenient single-drug regimen 2, 4
• Taking rivaroxaban with food is essential during this phase as it significantly improves drug absorption 1, 3
• The twice-daily dosing in the initial phase provides stronger anticoagulation when the thrombus burden is highest 2, 5

Maintenance Phase (After 21 Days)

• After the initial 21-day period, transition to rivaroxaban 20 mg once daily with food 1, 3
• The maintenance dose should continue for at least 3 months, with the total duration determined by underlying risk factors 2, 6
• For extended secondary prevention (after 6 months of initial therapy), a reduced dose of 10 mg once daily can be considered 1, 7
• Once-daily dosing during maintenance phase improves convenience and may enhance medication adherence 2, 6

Special Populations and Considerations

Cancer Patients

• Rivaroxaban is effective in cancer patients with DVT, with similar efficacy to standard therapy but potentially lower rates of major bleeding (2% vs 5%, HR 0.42) 1, 8
• For cancer patients, rivaroxaban can be used at the standard dosing regimen (15 mg twice daily for 21 days, then 20 mg once daily) 1, 8

Renal Impairment

• For patients with moderate renal impairment (creatinine clearance 30-49 mL/min), no dose adjustment is required for DVT treatment 1, 3
• Rivaroxaban should be avoided in patients with severe renal failure (creatinine clearance <15 mL/min) 1
• Use with caution in patients with creatinine clearance 15-29 mL/min 3

Monitoring and Follow-up

• No routine coagulation monitoring is required with rivaroxaban, unlike vitamin K antagonists 2, 1
• Neither PT (expressed in seconds or as a ratio) nor aPTT should be used to monitor the anticoagulant effect of rivaroxaban 1
• Baseline laboratory testing should include CBC, renal and hepatic function panel, aPTT, and PT/INR 1
• Follow-up testing should include hemoglobin, hematocrit, and platelet count at least every 2-3 days for the first 14 days and every 2 weeks thereafter 1

Practical Administration Tips

• If a dose is missed during the twice-daily treatment phase, the patient should take it immediately to ensure intake of 30 mg rivaroxaban per day 3
• For patients who cannot swallow tablets whole, rivaroxaban tablets can be crushed and mixed with applesauce immediately before use 3
• For patients requiring an NG tube or gastric feeding tube, crushed rivaroxaban tablets can be mixed with a small amount of water before administering via the tube 3

Clinical Evidence Supporting This Regimen

• The EINSTEIN-DVT trial demonstrated that rivaroxaban was non-inferior to standard therapy (enoxaparin/vitamin K antagonist) for preventing recurrent VTE (2.1% vs 3.0%, HR 0.68) 4, 6
• The single-drug approach with rivaroxaban resulted in similar efficacy to standard therapy but was associated with a significantly lower rate of major bleeding (1.0% vs 1.7%, HR 0.54) 6
• Efficacy and safety results were consistent across key patient subgroups, including fragile patients, cancer patients, and those with a history of recurrent VTE 6, 8