What is the recommended dosage and duration of Rivaroxaban (Xarelto) for Deep Vein Thrombosis (DVT) prophylaxis?

Rivaroxaban for DVT Prophylaxis

Recommended Dosing and Duration

For DVT prophylaxis after major orthopedic surgery, rivaroxaban 10 mg once daily is the recommended dose, initiated 6-10 hours after surgery once hemostasis is established, and continued for 10-14 days after total knee arthroplasty (TKA) or up to 35 days after total hip arthroplasty (THA). 1, 2

Orthopedic Surgery Prophylaxis

The specific dosing regimen varies by procedure type:

• Total Hip Arthroplasty (THA): 10 mg once daily for 28-35 days 1
• Total Knee Arthroplasty (TKA): 10 mg once daily for 10-14 days 1
• First dose timing: Administer 6-10 hours after surgery once adequate hemostasis is achieved 1, 2

Important Contraindications and Limitations

Rivaroxaban is NOT recommended for VTE prophylaxis in acutely ill general medical patients. 1 The MAGELLAN trial demonstrated that while rivaroxaban was noninferior to enoxaparin for VTE prevention in hospitalized medical patients, it was associated with significantly higher bleeding risk, making the risk-benefit ratio unfavorable in this population 1.

Similarly, rivaroxaban is not recommended for prophylactic or therapeutic anticoagulation in patients with active cancer due to insufficient data in this population (only 5-6% of trial participants had active cancer) 1.

Renal Function Considerations

Renal function is critical when prescribing rivaroxaban, as 66% of the drug undergoes renal excretion 1:

• Severe renal impairment (CrCl <30 mL/min): Rivaroxaban should be avoided 1, 2
• Moderate renal impairment (CrCl 30-50 mL/min): Use with caution; may require dose adjustment or alternative agent 1
• Creatinine clearance must be calculated using the Cockcroft-Gault formula before initiating therapy 1

Perioperative Management

When rivaroxaban must be interrupted for subsequent procedures:

• Low hemorrhagic risk procedures: Discontinue 3 days before the procedure when CrCl >30 mL/min 1
• High hemorrhagic risk procedures: Discontinue up to 5 days before the procedure, particularly for intracranial neurosurgery or neuraxial anesthesia 1
• No bridging therapy required in most cases, except for very high thrombotic risk patients 1

Resumption After Surgery

• Prophylactic anticoagulation: Can initiate heparin (UFH or LMWH) or fondaparinux at least 6 hours after the procedure 1
• Rivaroxaban resumption: Can be restarted at prophylactic doses within approved indications (THA or TKA) once surgical hemostasis is obtained 1

Common Pitfalls to Avoid

Timing Errors

• Do not administer rivaroxaban before adequate hemostasis is achieved post-operatively, as this significantly increases bleeding risk 1, 2
• Avoid premature discontinuation before completing the recommended duration (10-14 days for TKA, up to 35 days for THA) 1

Population-Specific Errors

• Do not use in acutely ill medical patients for VTE prophylaxis due to unfavorable bleeding risk 1
• Avoid in patients with severe renal impairment (CrCl <30 mL/min) 1, 2
• Do not use in cancer patients for prophylaxis or treatment until more data become available 1

Drug Interactions

• Monitor for P-glycoprotein inhibitors (e.g., ketoconazole, ritonavir) which can increase rivaroxaban levels 1
• Monitor for CYP3A4 inhibitors which affect rivaroxaban metabolism 1

Neuraxial Anesthesia

• Never perform spinal or epidural anesthesia with inadequate rivaroxaban discontinuation time, particularly in patients >80 years or with renal failure 1
• Ensure sufficient drug-free interval before neuraxial procedures to prevent spinal/epidural hematoma 1, 2

Comparison with Alternative Agents

While rivaroxaban is FDA-approved and effective for orthopedic surgery prophylaxis 1, LMWH (particularly enoxaparin) remains the preferred agent for:

• Acutely ill general medical patients 1
• Patients with active cancer 1
• Patients with severe renal impairment 1

The advantage of rivaroxaban is its oral administration and once-daily dosing without need for routine coagulation monitoring 3, 4, 5, but this convenience must be weighed against the inability to rapidly reverse its effects and the requirement for adequate renal function 1.