What is the preferred treatment between Xarelto (rivaroxaban) and Eliquis (apixaban) for Pulmonary Embolism (PE)?

Apixaban (Eliquis) vs Rivaroxaban (Xarelto) for Pulmonary Embolism

Apixaban is the preferred choice for PE treatment due to its superior bleeding safety profile, with major bleeding rates of only 0.6% compared to 1.1% with rivaroxaban, representing a 69% relative reduction in major bleeding risk. 1

Bleeding Safety: The Critical Differentiator

Apixaban demonstrates statistically superior bleeding outcomes:

• Major bleeding occurred in only 0.6% of apixaban patients versus 2.2% with conventional therapy (RR 0.31; 95% CI 0.17-0.55; P<0.001), achieving superiority rather than just non-inferiority 2, 1
• The composite outcome of major plus clinically relevant non-major bleeding was 4.3% with apixaban versus 9.7% with conventional therapy (RR 0.44; 95% CI 0.36-0.55; P<0.001) 2, 1

Rivaroxaban showed less impressive bleeding reduction:

• Major bleeding occurred in 1.1% of rivaroxaban patients versus 2.2% with standard therapy (HR 0.49; 95% CI 0.31-0.79) 2, 3
• The principal safety outcome (major or clinically relevant non-major bleeding) showed no significant difference between rivaroxaban and standard therapy (HR 0.90; 95% CI 0.76-1.07; P=0.23) 2, 3

Efficacy: Both Are Non-Inferior

Both agents demonstrate equivalent efficacy for preventing recurrent VTE:

• Apixaban: RR 0.84 (95% CI 0.60-1.18) for recurrent symptomatic VTE or VTE-related death 2
• Rivaroxaban: HR 1.12 (95% CI 0.75-1.68) for recurrent symptomatic VTE 2, 3

Since both are non-inferior to conventional therapy for efficacy, the decision hinges on safety and bleeding risk 4, 5.

Clinical Implementation Advantages

Apixaban offers practical benefits:

• Immediate initiation without parenteral anticoagulation: 10 mg twice daily for 7 days, then 5 mg twice daily 2, 1
• Associated with shorter hospital length of stay and faster time to discharge 1
• Particularly advantageous in patients at elevated bleeding risk where the 69% relative reduction in major bleeding provides critical safety margin 1

Rivaroxaban dosing:

• 15 mg twice daily for 3 weeks, followed by 20 mg once daily 2, 3
• Also allows single-drug approach without heparin lead-in 4

Guideline Perspective

The European Society of Cardiology recognizes all DOACs as viable alternatives to conventional therapy, noting they are "possibly safer (particularly in terms of major bleeding)" 2. However, the ESC specifically highlights apixaban's superior bleeding safety advantage 1. The British Thoracic Society recommends offering patients either LMWH/dabigatran or single-drug regimens with apixaban or rivaroxaban, with preference for a single DOAC to minimize confusion 1.

When to Consider Rivaroxaban

Rivaroxaban remains a reasonable alternative when:

• Patient preference favors once-daily dosing after the initial 3-week period 3
• Apixaban is unavailable or contraindicated
• Cost considerations favor rivaroxaban in specific healthcare systems

Common Pitfalls to Avoid

• Do not use either agent in severe renal failure (creatinine clearance <30 mL/min) 6
• Avoid in pregnancy and lactation - both are contraindicated 4
• Exercise caution in cancer patients with gastrointestinal malignancies due to increased bleeding risk 4
• Do not use in antiphospholipid antibody syndrome - warfarin remains the standard 4
• Ensure proper dose reduction for extended therapy beyond 6 months 4