What is the recommended dosing of Xarelto (rivaroxaban) for deep vein thrombosis (DVT) post-operatively?

Xarelto (Rivaroxaban) Dosing for Post-Operative DVT Treatment

For post-operative DVT treatment, start rivaroxaban 15 mg twice daily with food for 21 days, then transition to 20 mg once daily with food for continued treatment. 1, 2

Initial Treatment Phase (Days 1-21)

• Administer rivaroxaban 15 mg twice daily with food for the first 21 days to provide strong anticoagulation when thrombus burden is highest 1, 2, 3
• Food intake significantly improves drug absorption and ensures adequate anticoagulation during the acute phase 1
• No parenteral anticoagulation (heparin/LMWH) is required before starting rivaroxaban, making it a convenient single-drug regimen 1, 3
• This higher-intensity initial dosing has demonstrated superior D-dimer reduction rates (46% vs 26-27%) and faster normalization (18 days vs 24-26 days) compared to lower dose regimens 4

Timing of Post-Operative Initiation

The timing of rivaroxaban initiation depends on surgical bleeding risk and hemostasis:

Low Bleeding Risk Surgery

• Resume rivaroxaban 24 hours post-operatively at full treatment dose (15 mg twice daily) once hemostasis is assured 5

High Bleeding Risk Surgery

• Resume rivaroxaban 48-72 hours post-operatively (2-3 days after surgery) 5
• For patients at high thromboembolism risk, consider starting with a reduced dose of 10 mg once daily for the first 2-3 days, then transition to the standard 15 mg twice daily regimen 5

Bridging Considerations

• Prophylactic-dose LMWH or fondaparinux can be initiated 6-12 hours post-operatively if VTE prophylaxis is indicated while waiting to start therapeutic rivaroxaban 5
• When transitioning from prophylactic LMWH to therapeutic rivaroxaban, administer the first rivaroxaban dose 12 hours after the last prophylactic LMWH dose 5
• No therapeutic-dose heparin bridging is needed except in very high thrombotic risk patients 5

Maintenance Phase (After Day 21)

• Transition to rivaroxaban 20 mg once daily with food after completing the 21-day initial phase 1, 2, 3
• Continue for a minimum of 3 months, with total duration determined by underlying VTE risk factors 1
• For extended secondary prevention beyond 6 months, consider reducing to 10 mg once daily 1, 2

Special Considerations

Renal Impairment

• No dose adjustment needed for creatinine clearance 30-49 mL/min during DVT treatment 1
• Avoid rivaroxaban in severe renal failure (CrCl <15 mL/min) 1
• Monitor renal function post-operatively as surgical procedures may affect kidney function 5

Cancer Patients

• Use the same standard dosing regimen (15 mg twice daily × 21 days, then 20 mg once daily) 1
• Rivaroxaban demonstrates similar efficacy with potentially lower major bleeding rates (2% vs 5%) compared to standard therapy in cancer patients 1

Epidural Catheters

• Do not initiate therapeutic-dose rivaroxaban while an epidural catheter is in place 5
• Use prophylactic-dose heparin instead, which allows safe catheter management 5
• Only transition to therapeutic rivaroxaban after catheter removal 5

Critical Pitfalls to Avoid

• Never start with 20 mg once daily from day 1 - this provides inadequate anticoagulation during the acute phase when thrombus burden is highest 4, 6
• Do not resume therapeutic anticoagulation too early post-operatively - this significantly increases bleeding risk, particularly in major surgery 5
• Always administer with food - rivaroxaban absorption is significantly reduced without food, potentially leading to treatment failure 1, 2
• Avoid in patients with neuraxial anesthesia/epidural catheters until catheter removal to prevent spinal/epidural hematoma 5, 2

Monitoring

• No routine coagulation monitoring required unlike warfarin 1
• Baseline labs: CBC, renal and hepatic function, aPTT, PT/INR 1
• Follow-up: Hemoglobin, hematocrit, platelets every 2-3 days for first 14 days, then every 2 weeks 1
• Monitor for signs of bleeding or recurrent thrombosis 2