What is the recommended dose and treatment duration for a patient on Rivaroxaban (Xarelto)?

Rivaroxaban Dosing and Treatment Duration

The recommended dose and duration of rivaroxaban depends entirely on the indication: for VTE treatment, use 15 mg twice daily for 3 weeks followed by 20 mg once daily for a minimum of 3-6 months; for atrial fibrillation stroke prevention, use 20 mg once daily (15 mg if CrCl 30-49 mL/min); for post-orthopedic surgery VTE prophylaxis, use 10 mg once daily for 2 weeks (knee) or 5 weeks (hip). 1

VTE Treatment (DVT/PE)

Acute Phase Dosing

• Start with 15 mg twice daily for the first 3 weeks, which provides intensive anticoagulation during the acute thrombotic phase when recurrence risk is highest 1
• This twice-daily regimen was specifically designed to achieve strong antithrombotic effect during acute treatment 2, 3

Maintenance Phase Dosing

• After 3 weeks, transition to 20 mg once daily for continued treatment 1
• This maintenance dose balances efficacy against bleeding risk for long-term therapy 2, 3

Treatment Duration

• Minimum 3-6 months for provoked VTE (e.g., surgery-related, temporary risk factors) 1
• Extended therapy beyond 6 months for unprovoked VTE or recurrent events: Continue 20 mg once daily or consider dose reduction to 10 mg once daily for extended secondary prevention 1
• The 10 mg once daily dose for extended prophylaxis showed superior efficacy over placebo without significantly increased major bleeding 1

Atrial Fibrillation (Stroke Prevention)

• 20 mg once daily with the evening meal for patients with CrCl >50 mL/min 1, 4
• 15 mg once daily for patients with CrCl 30-49 mL/min 1
• Continue indefinitely as long as AF persists and stroke risk factors remain 1

Post-Orthopedic Surgery VTE Prophylaxis

Hip Replacement

• 10 mg once daily for 5 weeks (35 days) 1, 5
• Start 6-10 hours after surgery once hemostasis is established 1, 5

Knee Replacement

• 10 mg once daily for 2 weeks (10-14 days) 1
• Start 6-10 hours after surgery once hemostasis is established 1

Acute Coronary Syndrome (Secondary Prevention)

• 2.5 mg twice daily in combination with aspirin or dual antiplatelet therapy 1
• This lower dose reduces atherothrombotic events when added to antiplatelet therapy 1

Critical Dosing Considerations

Renal Impairment

• CrCl 30-49 mL/min: Reduce dose to 15 mg once daily for AF; use standard dosing for VTE treatment 1
• CrCl 15-29 mL/min: Use with extreme caution; limited data available 1
• CrCl <15 mL/min or dialysis: Contraindicated 1

Hepatic Impairment

• Contraindicated in hepatic disease associated with coagulopathy 1
• Rivaroxaban undergoes hepatic metabolism via CYP3A4 6

Drug Interactions

• Avoid concomitant use with strong dual inhibitors of CYP3A4 and P-glycoprotein (e.g., azole antifungals like ketoconazole, HIV protease inhibitors) 1, 6
• These combinations can significantly increase rivaroxaban levels and bleeding risk 6

Administration Guidelines

Food Requirements

• 15 mg and 20 mg tablets must be taken with food to ensure adequate absorption 4, 2
• 10 mg and 2.5 mg tablets can be taken with or without food 4
• For patients unable to swallow tablets, crush and mix with applesauce immediately before administration, followed by food 4

Missed Dose Management

• For twice-daily dosing (15 mg): Take immediately when remembered; can take two 15 mg doses simultaneously if needed 4
• For once-daily dosing (20 mg): Take as soon as remembered on the same day; do not double the dose the next day 4

Common Pitfalls to Avoid

Timing Errors

• Do not start rivaroxaban too early post-surgery before hemostasis is achieved, as this increases bleeding risk 5
• Do not use PT/INR or aPTT to monitor rivaroxaban effect—these tests are unreliable for this purpose 1

Duration Mistakes

• Do not stop rivaroxaban abruptly without alternative anticoagulation in place, as this increases thrombotic risk 4
• Do not use inadequate treatment duration for VTE (minimum 3 months for most cases) 1

Special Population Errors

• Do not use in pregnancy or breastfeeding—rivaroxaban crosses the placenta and is secreted in breast milk 1
• Do not use in children under 2.6 kg or without appropriate pediatric dosing tables 1

Drug Interaction Oversights

• Screen for azole antifungals and HIV protease inhibitors before prescribing 1, 6
• Assess renal function before initiating and periodically during treatment 1

Pediatric Dosing (Ages ≥2.6 kg)

• Weight-based dosing using oral suspension or tablets depending on body weight 1
• <12 kg: Three times daily dosing with oral suspension 1
• 12-30 kg: 5 mg twice daily 1
• 30-50 kg: 15 mg once daily 1
• ≥50 kg: 20 mg once daily (adult dosing) 1