Rivaroxaban for VTE Prophylaxis After Hip Fracture Surgery
For VTE prophylaxis after hip fracture surgery, administer rivaroxaban 10 mg once daily, starting 6-10 hours after surgery once hemostasis is established, and continue for 35 days. 1
Dosing Regimen
- Dose: 10 mg orally once daily 1
- Timing of initiation: 6-10 hours after surgery once hemostasis has been established 1
- Duration: 35 days total 2, 1
- Food requirements: Can be taken with or without food 1
This regimen mirrors the FDA-approved dosing for hip replacement surgery and is supported by the ACCP guidelines for major orthopedic procedures 2, 1.
Evidence Supporting This Approach
The 10 mg once-daily dose of rivaroxaban has demonstrated superior efficacy compared to enoxaparin 40 mg once daily in preventing postoperative VTE after major hip surgery 3. In the largest trial, total VTE occurred in only 1.1% of rivaroxaban recipients versus 3.7% of enoxaparin recipients, representing an absolute risk reduction of 2.6% 3. Importantly, this enhanced efficacy was achieved without a significant increase in major bleeding events 3, 4.
Extended prophylaxis with rivaroxaban for 35 days significantly reduced symptomatic VTE compared to shorter-duration LMWH (12 days) followed by placebo, with symptomatic DVT reduced by 82% (RR 0.18) 2.
Alternative Approach: Sequential Therapy
Recent evidence suggests an alternative strategy that may be equally effective and more cost-efficient:
- Initial phase: Enoxaparin for 5 days postoperatively 5
- Extended phase: Switch to either aspirin 100 mg once daily OR continue rivaroxaban 10 mg once daily for an additional 16 days (total 21 days) 5
In a study of 390 hip fracture surgery patients, this sequential approach showed equivalent VTE rates between aspirin (6.6%) and rivaroxaban (5.7%) groups, with similar bleeding rates 5. This strategy may offer a practical, cost-effective alternative while maintaining safety and efficacy 5.
Renal Dosing Considerations
- CrCl ≥15 mL/min: No dose adjustment needed; use standard 10 mg once daily 1
- CrCl <15 mL/min: Avoid rivaroxaban use 1
The predictable pharmacokinetics of rivaroxaban eliminate the need for routine coagulation monitoring, unlike warfarin 2, 4.
Critical Safety Considerations
Timing of Initiation
Never start rivaroxaban too early postoperatively. The 6-10 hour window after surgery is critical to balance VTE prevention against bleeding risk 1. Starting earlier significantly increases bleeding complications, particularly in major orthopedic surgery 6.
Neuraxial Anesthesia
Do not initiate therapeutic-dose rivaroxaban while an epidural catheter is in place. This creates substantial risk for spinal/epidural hematoma, which can result in permanent paralysis 1. If neuraxial anesthesia was used, ensure the catheter is removed before starting rivaroxaban 6.
Bleeding Risk
Major bleeding shows a dose-dependent relationship with rivaroxaban 7, 4. The 10 mg once-daily dose represents the optimal balance between efficacy and safety, with major bleeding rates of 0.9-2.3% compared to 1.7-1.9% with enoxaparin 7, 4.
Comparison to Other Anticoagulants
While LMWH (enoxaparin 40 mg once daily or 30 mg twice daily) remains the traditional standard, rivaroxaban offers several advantages 2:
- Oral administration versus subcutaneous injection
- No need for coagulation monitoring 2, 4
- Superior efficacy in preventing symptomatic VTE 3
- Similar or lower bleeding rates 3, 5
The ACCP guidelines note that despite rivaroxaban's superior efficacy, the long-term safety data for LMWH and the inconvenience trade-off should be considered 2. However, for hip fracture surgery specifically, the 35-day oral regimen offers substantial practical advantages over daily injections 1.
Contraindications
- Active pathological bleeding 1
- Severe hypersensitivity to rivaroxaban 1
- CrCl <15 mL/min 1
- Concomitant use with potent CYP3A4 and P-glycoprotein inhibitors (ketoconazole, ritonavir) 2