What is the dose of Xarelto (rivaroxaban) for atrial fibrillation (a fib)?

Rivaroxaban Dosing for Atrial Fibrillation

For patients with atrial fibrillation, rivaroxaban should be administered at a dose of 20 mg once daily with the evening meal, with a reduced dose of 15 mg once daily with the evening meal for patients with creatinine clearance 15-50 mL/min. 1, 2

Standard Dosing

• The standard dose for rivaroxaban in nonvalvular atrial fibrillation is 20 mg once daily 1
• Rivaroxaban must be taken with food, specifically with the evening meal, to ensure adequate absorption 3, 2
• Taking rivaroxaban with food increases its bioavailability and ensures consistent anticoagulant effect 3, 2

Renal Adjustment

• For patients with moderate renal impairment (creatinine clearance 15-50 mL/min), the dose should be reduced to 15 mg once daily with the evening meal 1, 2
• This dose reduction was validated in the ROCKET AF trial, which showed consistent treatment effect in patients with renal impairment receiving the reduced dose 4, 5
• Patients with severe renal impairment (creatinine clearance <15 mL/min) were not included in major trials and rivaroxaban is generally not recommended for these patients 1

Administration Considerations

• Rivaroxaban should be taken at approximately the same time each day 2
• If a dose is missed, the patient should take it as soon as possible on the same day 2
• For patients who cannot swallow tablets whole, rivaroxaban tablets can be crushed and mixed with applesauce followed by food 2

Clinical Evidence

• The ROCKET AF trial demonstrated that rivaroxaban was noninferior to warfarin for preventing stroke and systemic embolism in patients with nonvalvular atrial fibrillation 1, 5
• Rivaroxaban showed similar rates of major bleeding compared to warfarin, but with significantly less intracranial hemorrhage (0.5% vs. 0.7%) and fatal bleeding (0.2% vs. 0.5%) 5
• Recent comparative effectiveness research suggests that apixaban may have a more favorable safety profile than rivaroxaban, with lower rates of major ischemic and hemorrhagic events 6

Common Pitfalls

• Inappropriate dose reduction is common in clinical practice, with one study finding that 52.1% of patients receiving reduced-dose rivaroxaban did not meet labeling criteria for dose reduction 7
• Taking rivaroxaban without food, especially at the 20 mg and 15 mg doses, can significantly reduce drug absorption and potentially compromise efficacy 3, 2
• Drug interactions with P-glycoprotein and CYP3A4 inducers or inhibitors can affect rivaroxaban levels and should be considered when prescribing 3

Monitoring

• Routine monitoring of coagulation parameters is generally not required for rivaroxaban 4
• Renal function should be assessed before initiating therapy and periodically during treatment, especially in elderly patients or those with fluctuating renal function 1