What is the recommended dosage of Xarelto (rivaroxaban) for patients at risk of blood clots?

Xarelto (Rivaroxaban) Dosing for Blood Clot Prevention

For stroke prevention in atrial fibrillation, use rivaroxaban 20 mg once daily with food (or 15 mg once daily if creatinine clearance is 15-50 mL/min); for acute DVT/PE treatment, start with 15 mg twice daily with food for 21 days, then transition to 20 mg once daily for continued treatment. 1

Atrial Fibrillation (Stroke Prevention)

Standard dosing:

• 20 mg once daily with the evening meal for patients with CrCl >50 mL/min 2, 1, 3
• 15 mg once daily with food for patients with CrCl 15-50 mL/min 2, 1

The ROCKET-AF trial demonstrated rivaroxaban was noninferior to warfarin in preventing ischemic stroke or systemic embolism, with fewer intracranial and fatal bleeding events 2. NOACs like rivaroxaban should be preferred over warfarin in most patients and used at established stroke prevention doses—lower doses are not recommended unless specifically tested. 2

Venous Thromboembolism (DVT/PE) Treatment

Acute phase (first 21 days):

• 15 mg twice daily with food 2, 1

Maintenance phase (after 21 days):

• 20 mg once daily with food for patients with CrCl >50 mL/min 2, 4, 1
• 15 mg once daily with food for patients with CrCl 30-50 mL/min 4, 1

The EINSTEIN trials showed rivaroxaban 15 mg twice daily for 3 weeks followed by 20 mg once daily was noninferior to enoxaparin/warfarin for acute VTE treatment, with a hazard ratio of 0.68 (95% CI 0.44-1.04) for recurrent VTE 2.

Extended VTE Prevention (After Initial Treatment)

For patients with unprovoked proximal DVT or PE who have completed initial 3-6 months of treatment:

• 20 mg once daily for extended anticoagulation with no scheduled stop date 4
• 10 mg once daily is an alternative for patients at continued risk of recurrent DVT/PE after at least 6 months of initial treatment 1, 3

The EINSTEIN Extension trial demonstrated rivaroxaban 20 mg once daily was superior to placebo in preventing recurrent VTE (1.3% vs 7.1% recurrence rate) when continued for an additional 6-12 months 4. Extended anticoagulation is recommended when bleeding risk is low to moderate, with annual reassessment required. 4

VTE Prophylaxis After Orthopedic Surgery

• 10 mg once daily (with or without food) starting 6-10 hours after surgery 1, 3
• Duration: 2 weeks for total knee replacement, 5 weeks for total hip replacement 1

The RECORD trials showed rivaroxaban 10 mg once daily was more effective than enoxaparin 40 mg once daily in preventing postoperative VTE without significantly increasing major bleeding (0.1-0.7% vs similar rates with enoxaparin) 2.

Critical Renal Function Adjustments

CrCl (mL/min)	Atrial Fibrillation	VTE Treatment (Maintenance)	VTE Prophylaxis
>50	20 mg daily	20 mg daily	10 mg daily
30-50	15 mg daily	15 mg daily	10 mg daily
15-30	15 mg daily	15 mg daily	10 mg daily
<15	15 mg daily (AF only)	Not recommended	Not recommended

1

Rivaroxaban is contraindicated in patients with CrCl <15 mL/min for VTE treatment and prophylaxis, but can be used for atrial fibrillation at 15 mg daily. 1, 5

Administration Requirements

Food requirements vary by dose:

• 15 mg and 20 mg tablets must be taken with food to ensure adequate absorption 1, 3
• 10 mg and 2.5 mg tablets can be taken with or without food 1, 3

For patients unable to swallow tablets:

• Crush tablet and mix with small amount of applesauce, followed by food 3
• For NG/gastric feeding tubes: crush tablet and mix with small amount of water before administering 3

Absolute Contraindications

Do not use rivaroxaban in:

• Active pathological bleeding 1, 3
• Severe hepatic impairment (Child-Pugh B or C) or hepatic disease with coagulopathy 4, 1, 5
• Concomitant systemic treatment with azole antimycotics (e.g., ketoconazole) or HIV protease inhibitors 4, 5
• Prosthetic heart valves 1
• Triple positive antiphospholipid syndrome 1
• Pregnancy and breastfeeding 1

Periprocedural Management

For elective procedures:

• Low bleeding risk: Stop 24 hours (1 day) before procedure if CrCl >30 mL/min 1
• High bleeding risk: Stop 48 hours (2 days) before procedure if CrCl >30 mL/min 1

For patients with renal impairment or elderly patients, consider longer discontinuation intervals (20-30 hours or more) to normalize bleeding risk. 6

Bleeding Risk Considerations

Major bleeding rates:

• VTE prophylaxis (orthopedic surgery): 0.1-0.7% 2
• Extended VTE treatment: 0.7% annually 4
• Atrial fibrillation: Similar to warfarin but with fewer intracranial hemorrhages 2

Consider PPI prophylaxis when combining rivaroxaban with corticosteroids or antiplatelet agents. 1 Concomitant use of NSAIDs or antiplatelet agents does not significantly increase bleeding risk based on pooled RECORD trial analysis, though caution remains warranted 2, 4.

Common Pitfalls to Avoid

• Never use lower than recommended doses unless specifically tested for that indication—underdosing increases thrombotic risk without reducing bleeding 2
• Do not discontinue prematurely without consulting healthcare provider, as stopping increases thrombotic event risk 3
• Do not use rivaroxaban with severe thrombocytopenia (platelets <50 × 10⁹/L)—switch to LMWH at reduced doses 5
• Avoid routine coagulation monitoring (PT/aPTT should not be used to monitor rivaroxaban effect) 4

Reversal Options

For life-threatening bleeding:

• Andexanet alfa is the specific reversal agent 1
• Four-factor prothrombin complex concentrate (PCC) if andexanet alfa unavailable 1, 6
• Supportive measures including mechanical compression, blood products, and tranexamic acid 6