What arrhythmias are indications for Rivaroxaban (Xarelto)?

From the Guidelines

Rivaroxaban is primarily used for the management of non-valvular atrial fibrillation (AF) to reduce the risk of stroke and systemic embolism, and it is not typically used for other arrhythmias such as ventricular tachycardia, ventricular fibrillation, or supraventricular tachycardias. The standard dosing for atrial fibrillation is 20 mg once daily with food for patients with normal renal function (CrCl >50 mL/min), or 15 mg once daily with food for those with reduced renal function (CrCl 15-50 mL/min) 1. Rivaroxaban works by directly inhibiting Factor Xa in the coagulation cascade, preventing thrombin formation and subsequent clot development. This mechanism is particularly important in atrial fibrillation because the irregular heart rhythm can cause blood to pool in the atria, especially the left atrial appendage, increasing the risk of clot formation that could lead to stroke if dislodged 1.

Some key points to consider when using rivaroxaban for AF include:

• The CHA2DS2-VASc score is recommended for assessment of stroke risk in patients with AF, except those with moderate or severe mitral stenosis or a mechanical heart valve 1.
• Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent 1.
• Anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative risks of stroke and bleeding, as well as the patient’s values and preferences 1.
• Patients should be aware that rivaroxaban should not be stopped abruptly due to increased thrombotic risk, and any planned discontinuation should be discussed with a healthcare provider to determine if bridge therapy is needed.

It's worth noting that the most recent and highest quality study, which is from 2021 1, provides the most up-to-date guidance on the use of rivaroxaban for AF, and it recommends the use of DOACs, including rivaroxaban, over warfarin in DOAC-eligible patients with AF, except those with moderate or severe mitral stenosis or a mechanical heart valve.

From the FDA Drug Label

XARELTO is a factor Xa inhibitor indicated: to reduce risk of stroke and systemic embolism in nonvalvular atrial fibrillation ( 1.1) The main arrhythmia used for rivaroxaban is nonvalvular atrial fibrillation 2.

• The FDA label does not mention other types of arrhythmias as indications for rivaroxaban.

From the Research

Rivaroxaban and Arrhythmias

Rivaroxaban is used to prevent stroke and systemic embolism in patients with certain arrhythmias, specifically:

• Nonvalvular atrial fibrillation (NVAF) 3, 4, 5, 6
• Atrial fibrillation (AF) 3, 7, 6

Approved Indications

The approved indications for rivaroxaban include:

• Reduction of risk of stroke and systemic embolism in nonvalvular atrial fibrillation 4
• Treatment of deep vein thrombosis (DVT) 4
• Treatment of pulmonary embolism (PE) 4
• Reduction in the risk of recurrence of DVT and/or PE 4
• Prophylaxis of DVT following hip or knee replacement surgery 4
• Prophylaxis of venous thromboembolism in acutely ill medical patients at risk for thromboembolic complications not at high risk of bleeding 4
• Reduction of risk of major cardiovascular events in patients with chronic coronary artery disease or peripheral artery disease 4

Dosage and Administration

The dosage and administration of rivaroxaban vary depending on the indication and renal function:

• 20 mg once daily for patients with normal renal function 3, 5
• 15 mg once daily for patients with moderate renal impairment (creatinine clearance 30-49 mL/min) 3, 5
• 15 mg once daily in the Japanese population 3
• 10 mg once daily in patients with moderate renal impairment in the Japanese population 3