How to transition from Eliquis (apixaban) to Xarelto (rivaroxaban)?

Transitioning from Apixaban (Eliquis) to Rivaroxaban (Xarelto)

Simply stop apixaban and start rivaroxaban at the next scheduled dose without any overlap or bridging anticoagulation. Both drugs are direct oral anticoagulants (DOACs) with rapid onset of action, making direct switching safe and straightforward.

Practical Transition Protocol

Timing of the Switch

• Stop apixaban at its regularly scheduled time (typically taken twice daily) 1
• Start rivaroxaban at the time of the next scheduled apixaban dose 1
• No washout period is required between these medications 1
• No bridging with heparin or low-molecular-weight heparin (LMWH) is necessary 1

Dosing Considerations Based on Indication

The rivaroxaban dose depends on the clinical indication:

For Atrial Fibrillation:

• Standard dose: 20 mg once daily with food 1
• Reduced dose: 15 mg once daily if creatinine clearance is 30-49 mL/min 1

For Venous Thromboembolism (VTE) Treatment:

• Acute phase (first 21 days): 15 mg twice daily with food 1
• Maintenance phase (after 21 days): 20 mg once daily with food 1
• If switching during acute VTE treatment while on apixaban's loading dose (10 mg twice daily for 7 days), complete the apixaban loading regimen first before transitioning to rivaroxaban's maintenance dose 1

For Extended VTE Prevention (after 6 months):

• Reduced-intensity option: 10 mg once daily 1

Key Pharmacokinetic Differences to Consider

Apixaban Characteristics:

• Half-life: 7-8 hours in young patients, approximately 12 hours overall 2, 3
• Renal clearance: 25-27% 2, 3
• Dosing: Twice daily 1
• Bioavailability: ~50%, not significantly affected by food 3

Rivaroxaban Characteristics:

• Half-life: 5-9 hours in young patients, 11-13 hours in elderly 4
• Renal clearance: Higher than apixaban (predominantly renal) 4
• Dosing: Once daily 1
• Bioavailability: 80-100% for 10 mg dose; 15 mg and 20 mg tablets MUST be taken with food for optimal absorption 4

Critical Clinical Pitfalls to Avoid

Food Requirement for Rivaroxaban

The most important difference: Rivaroxaban 15 mg and 20 mg tablets must be taken with food to ensure adequate absorption 4. This is not required for apixaban 3. Patient education on this point is essential to prevent subtherapeutic anticoagulation.

Renal Function Monitoring

• Rivaroxaban has greater renal dependence than apixaban 4, 3
• Ensure creatinine clearance is documented before switching 1
• Avoid rivaroxaban in severe renal impairment (CrCl <30 mL/min for VTE; CrCl <15 mL/min for atrial fibrillation) 1

Drug-Drug Interactions

• Both medications are substrates of P-glycoprotein and CYP3A4 1
• Review for strong P-glycoprotein inhibitors (e.g., verapamil, dronedarone) and CYP3A4 inhibitors that may require dose adjustments 1

Special Population: Cancer-Associated VTE

• For patients with gastrointestinal or gastroesophageal malignancies, apixaban may be safer than rivaroxaban due to lower bleeding risk 1
• Consider whether the switch is truly necessary in this population 1

No Bridging Required

Unlike transitions involving warfarin, no bridging anticoagulation with heparin or LMWH is needed when switching between DOACs 1. The rapid onset of action of rivaroxaban (peak effect at 2-4 hours) provides immediate anticoagulation 4.

Documentation and Patient Education

• Document the reason for switching anticoagulants
• Educate patient on the once-daily dosing schedule (versus twice daily with apixaban)
• Emphasize taking rivaroxaban 15 mg or 20 mg with food 4
• Provide clear instructions on timing (preferably with the evening meal for consistency)
• Ensure patient understands not to double up if a dose is missed