What is the recommended dose of Xarelto (rivaroxaban) in the morning?

Xarelto (Rivaroxaban) Morning Dosing

Rivaroxaban 15 mg and 20 mg doses must be taken with the evening meal, not in the morning, to ensure adequate absorption. 1

Dose-Specific Administration Requirements

Higher Doses (15 mg and 20 mg)

• Must be taken with food, specifically with the evening meal 2, 1, 3
• Food intake is critical for adequate absorption at these doses 1
• The evening timing is recommended by the American College of Cardiology to ensure consistent anticoagulant effect 1, 3

Lower Doses (2.5 mg and 10 mg)

• Can be taken with or without food 1
• No specific meal timing requirement for these doses 1

Standard Dosing for Atrial Fibrillation

Normal Renal Function

• 20 mg once daily with the evening meal 2, 3
• This is the standard dose for patients with CrCl >50 mL/min 2

Moderate Renal Impairment (CrCl 30-49 mL/min)

• 15 mg once daily with the evening meal 2, 3
• This dose reduction was validated in the ROCKET AF trial and showed similar serum concentrations and clinical outcomes as 20 mg in patients with better renal function 3

Severe Renal Impairment (CrCl 15-30 mL/min)

• 15 mg once daily with the evening meal 2
• However, rivaroxaban is generally not recommended in severe renal impairment according to European guidelines 3

End-Stage Renal Disease

• Not recommended in patients on dialysis or with CrCl <15 mL/min due to lack of clinical trial evidence 2

Critical Timing Considerations

The evening meal timing is not arbitrary—it is a pharmacokinetic requirement for higher doses. 1 Unlike lower doses that can be taken flexibly, the 15 mg and 20 mg doses require food for proper absorption, and the evening timing provides consistency in anticoagulant effect throughout the 24-hour dosing interval 1, 3.

Pharmacokinetic Properties

• Time to peak plasma concentration: 2-4 hours after ingestion 2
• Half-life: 5-13 hours 2
• Therapeutic anticoagulation is restored within 3 hours of taking a dose 2
• Bioavailability: 66% fasting, 80-100% with food 2

Monitoring Requirements

• Assess renal function before initiating therapy 2, 3
• Recheck renal function annually in stable patients 3
• Monitor 2-3 times per year in patients with moderate renal impairment (CrCl 30-49 mL/min) 3

Drug Interactions Affecting Timing

• Avoid concomitant use with combined P-glycoprotein and strong CYP3A4 inhibitors (e.g., ketoconazole) in patients with CrCl 15-80 mL/min 2
• Avoid P-glycoprotein/CYP3A4 inducers (e.g., carbamazepine, phenytoin, rifampin, St. John's wort) 2

Common Pitfall to Avoid

Do not prescribe morning dosing for 15 mg or 20 mg rivaroxaban. The requirement for evening administration with food is based on pharmacokinetic data showing inadequate absorption without food at these doses 1. This is not a flexible recommendation—it is a dosing requirement for efficacy 1, 3.