What is the recommended dosing for Xarelto (rivaroxaban) in the treatment of acute Deep Vein Thrombosis (DVT)?

Xarelto Dosing for Acute DVT

For acute deep vein thrombosis, start rivaroxaban 15 mg orally twice daily with food for exactly 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 of treatment, as this higher-intensity dosing provides stronger anticoagulation when thrombus burden is highest 1, 2
• Food intake is critical during this phase because it significantly improves drug absorption and bioavailability 2, 3
• No parenteral anticoagulation (heparin or enoxaparin) is required before starting rivaroxaban, making it a convenient single-drug regimen unlike dabigatran or edoxaban which require 5-10 days of parenteral lead-in 1, 2
• This 21-day intensive phase is supported by the EINSTEIN-DVT trial demonstrating non-inferiority to standard enoxaparin/warfarin therapy with recurrence rates of 2.1% versus 2.3% 4, 5

Maintenance Phase (After Day 21)

• Transition to rivaroxaban 20 mg once daily with food after completing the 21-day initial phase 1, 2
• Continue this maintenance dose for a minimum of 3 months, with total duration determined by VTE risk factors (provoked versus unprovoked, presence of cancer, thrombophilia) 2, 6
• The once-daily maintenance dosing improves adherence compared to twice-daily regimens while maintaining efficacy 6

Extended Secondary Prevention (After 6 Months)

• For patients requiring indefinite anticoagulation after completing at least 6 months of full-dose therapy, reduce to rivaroxaban 10 mg once daily (with or without food) 1, 2
• This reduced-intensity dosing is validated by the EINSTEIN-CHOICE trial and balances recurrence prevention against bleeding risk 1, 7
• The alternative is continuing 20 mg once daily; choose based on individual bleeding risk versus recurrence risk 2, 6

Special Populations

Cancer-Associated DVT

• Use the same standard dosing regimen (15 mg twice daily for 21 days, then 20 mg once daily) in cancer patients 1, 2
• Rivaroxaban demonstrates similar efficacy to LMWH with potentially lower major bleeding rates (2% versus 5%, HR 0.42) 2
• Caution in gastrointestinal and genitourinary malignancies due to higher bleeding risk with DOACs 1

Renal Impairment

• No dose adjustment needed for creatinine clearance 30-49 mL/min during DVT treatment 2
• Avoid rivaroxaban if creatinine clearance <15 mL/min 2
• For creatinine clearance 15-30 mL/min, consider reducing to 15 mg once daily after the initial phase, though evidence is limited 6

Hepatic Impairment

• Avoid rivaroxaban in moderate-to-severe liver disease or hepatic coagulopathy 1, 2

Administration Considerations

• Patients unable to swallow tablets whole can crush rivaroxaban and mix with applesauce followed by food 3
• For nasogastric or gastric feeding tubes, crush the tablet and mix with water before administering via the tube 3
• No routine coagulation monitoring required, unlike warfarin, though baseline CBC, renal function, hepatic function, aPTT, and PT/INR should be obtained 2

Critical Safety Points

• Major bleeding occurred in 1.0% of rivaroxaban-treated patients versus 1.7% with standard therapy (HR 0.54,95% CI 0.37-0.79) in pooled EINSTEIN trials 4
• Patients should report unusual bleeding or bruising and understand they may bleed longer than usual 3
• Inform all healthcare providers (including dentists) about rivaroxaban use before any invasive procedures 3
• Do not discontinue rivaroxaban without consulting the prescribing physician, as this increases thrombosis risk 3

Missed Dose Management

• For the 15 mg twice-daily phase: Take the missed dose immediately and continue with twice-daily dosing; do not double up 3
• For the 20 mg once-daily phase: Take the missed dose as soon as remembered on the same day, then resume normal schedule 3

Common Pitfall to Avoid

Do not confuse VTE dosing with atrial fibrillation dosing. The VTE maintenance dose is 20 mg daily, not the 15 mg daily used in some AF studies like PIONEER-AF 1. Using subtherapeutic doses increases recurrence risk without reducing bleeding.