What is the recommended use and dosage of Rivaroxaban (Xarelto) for thromboembolic disorders?

Rivaroxaban Dosing for Thromboembolic Disorders

Rivaroxaban should be dosed at 15 mg twice daily with food for the first 21 days followed by 20 mg once daily with food for the treatment of venous thromboembolism (VTE), with dose reduction to 10 mg once daily considered after 6 months for extended secondary prevention. 1

Initial Treatment of VTE (DVT/PE)

• For acute deep vein thrombosis (DVT) and pulmonary embolism (PE), rivaroxaban should be administered at 15 mg orally twice daily with food for the first 21 days 1
• After the initial 21-day treatment period, transition to 20 mg once daily with food for continued treatment 1
• No initial parenteral anticoagulation is required before starting rivaroxaban, unlike some other direct oral anticoagulants (DOACs) such as dabigatran and edoxaban which require 5-10 days of parenteral lead-in therapy 1
• Administration with food is essential for the 15 mg and 20 mg doses to ensure optimal absorption 2

Extended Secondary Prevention of VTE

• After completing 6 months of initial therapy at 20 mg daily, either continue 20 mg once daily with food or reduce to 10 mg once daily with or without food for extended secondary prevention 1
• The reduced dose of 10 mg daily for secondary prevention may help decrease bleeding risk while maintaining efficacy 1

Special Populations and Considerations

• Rivaroxaban is contraindicated in patients with severe renal impairment (CrCl <30 mL/min) for VTE treatment 1, 3
• Use with caution in patients with moderate renal impairment (CrCl 30-50 mL/min) 1
• Elderly patients (>75 years) should use rivaroxaban with caution due to prolonged half-life (11-13 hours vs 5-9 hours in younger adults) 1, 4
• Rivaroxaban is primarily eliminated via the kidneys (66% renal excretion), making renal function assessment critical before and during therapy 1, 4
• For patients who cannot swallow tablets, rivaroxaban tablets may be crushed and mixed with applesauce immediately prior to use 2

Missed Doses

• For patients on 15 mg twice daily: Take missed dose immediately to ensure total daily intake of 30 mg; two 15 mg tablets may be taken at once 2
• For patients on 20 mg once daily: Take missed dose immediately on the same day; do not double the dose to make up for a missed dose 2

Perioperative Management

• Discontinue rivaroxaban at least 24 hours before elective procedures to reduce bleeding risk 2, 5
• For emergency surgery, comprehensive hemostasis management may be required, including potential use of prothrombin complex concentrate for life-threatening bleeding 5

Transitioning Between Anticoagulants

• When switching from rivaroxaban to warfarin in adults, discontinue rivaroxaban and begin both parenteral anticoagulant and warfarin at the time the next rivaroxaban dose would have been taken 2
• When switching from other anticoagulants to rivaroxaban, start rivaroxaban 0-2 hours prior to the next scheduled dose of the other anticoagulant 2

Monitoring

• Routine coagulation monitoring is not required for rivaroxaban due to its predictable pharmacokinetics and pharmacodynamics 6, 5
• If assessment of anticoagulant effect is needed (e.g., emergency situations), anti-Factor Xa chromogenic assays can provide quantitative measurement of rivaroxaban levels 5

Rivaroxaban's once-daily dosing (after initial therapy), predictable anticoagulant effect, and no requirement for routine monitoring make it a convenient option for VTE treatment, though careful patient selection based on renal function, age, and concomitant medications is essential for safe and effective use 6, 7.