From the Guidelines
After completing the Xarelto starter pack, patients should typically continue with Xarelto 20 mg once daily with food for most indications such as atrial fibrillation or deep vein thrombosis treatment, as recommended by the most recent guidelines 1. The dose may need to be adjusted based on renal function, with a reduced dose of 15 mg once daily with food for patients with moderate to severe renal impairment (creatinine clearance 15-50 mL/min) 1. Key considerations for prescribing Xarelto after the starter pack include:
- Duration of therapy: lifelong for atrial fibrillation, typically 3-6 months for provoked DVT/PE, and potentially longer for unprovoked events 1
- Consistent dosing: patients should take the medication at the same time each day to maintain consistent blood levels
- Bleeding risks: counsel patients about the importance of reporting unusual bleeding or bruising immediately, and inform all healthcare providers about their anticoagulant use before procedures
- Renal function monitoring: regular monitoring of renal function is recommended, though routine coagulation monitoring is not required 1 It's also important to note that the American Society of Hematology 2020 guidelines suggest that the standard dose or a lower dose of rivaroxaban may be used for secondary prevention of VTE, but additional research is necessary to identify which subsets of patients can safely use a lower-dose DOAC 1.
From the FDA Drug Label
For the tablets, advise the patient and/or caregiver to read the FDA-approved patient labeling (Medication Guide). Advise patients who are at a continued risk of recurrent DVT and/or PE after at least 6 months of initial treatment, to take XARELTO 10 mg once daily with or without food [see Dosage and Administration (2.1)]. If a dose is missed, advise the patient according to the instructions in the Full Prescribing Information based on their dosing schedule [see Dosage and Administration (2. 5)]
To prescribe XARELTO after the starter pack, patients at continued risk of recurrent DVT and/or PE should take 10 mg once daily with or without food. If a dose is missed, advise the patient according to the instructions in the Full Prescribing Information based on their dosing schedule 2.
From the Research
Prescribing Xarelto After the Starter Pack
To prescribe Xarelto (rivaroxaban) after the starter pack, consider the following:
- The initial treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) typically involves a starter pack, which may include a higher dose of rivaroxaban for the first few weeks 3.
- After the starter pack, the maintenance dose of rivaroxaban is usually 20mg once daily 3.
- The decision to extend prophylaxis with rivaroxaban should be based on the individual patient's risk of recurrent venous thromboembolism (VTE) and the risk of anticoagulant-related bleeding 3, 4.
- Rivaroxaban has been shown to be effective and safe for the treatment of DVT and PE, with a lower risk of major bleeding compared to traditional anticoagulants such as warfarin 3, 5.
- In patients with unusual site DVT, rivaroxaban has been shown to be comparable to warfarin in terms of efficacy, with a lower risk of bleeding complications and major bleeding 5.
- For patients with upper extremity DVT, rivaroxaban and apixaban have been shown to be safe and effective, with a low risk of recurrent VTE and bleeding complications 6.
Key Considerations
- Patient's renal function and liver function should be monitored regularly while on rivaroxaban 3.
- Patients should be instructed to take rivaroxaban with food to reduce the risk of gastrointestinal side effects 3.
- The risk of bleeding should be carefully assessed in patients taking rivaroxaban, particularly in those with a history of bleeding disorders or concomitant use of other anticoagulants 3, 4.