What are the guidelines for switching from Eliquis (apixaban) to Xarelto (rivaroxaban)?

Switching from Eliquis (Apixaban) to Xarelto (Rivaroxaban)

When switching from apixaban to rivaroxaban, discontinue apixaban and start rivaroxaban at the time of the next scheduled apixaban dose—no overlap or bridging anticoagulation is required. 1

Practical Switching Protocol

Timing of the Switch

• Stop apixaban and immediately start rivaroxaban at the next scheduled dose time 1
• No washout period is necessary between these two direct oral anticoagulants 1
• No bridging with heparin or low-molecular-weight heparin is required 1

Dosing Considerations

For Atrial Fibrillation:

• Standard rivaroxaban dose: 20 mg once daily with the evening meal 1
• Dose reduction to 15 mg once daily if creatinine clearance 15-50 mL/min 1

For Venous Thromboembolism:

• Initial treatment: 15 mg twice daily with food for 21 days, then 20 mg once daily 1
• If switching from apixaban maintenance therapy (already past acute phase), start directly with 20 mg once daily 1

Key Pharmacokinetic Differences to Consider

Apixaban characteristics:

• Half-life: 12 hours 1
• Twice daily dosing 1
• 27% renal elimination 1
• Taken with or without food 1

Rivaroxaban characteristics:

• Half-life: 5-13 hours 1
• Once daily dosing 1
• 35% renal elimination 1
• Must be taken with food for proper absorption 1

Critical Safety Considerations

Patient Education Points

• Emphasize that rivaroxaban MUST be taken with food to ensure adequate absorption—this is a critical difference from apixaban 1
• Rivaroxaban is once daily (typically evening dose), whereas apixaban was twice daily 1
• Missing a dose of rivaroxaban leaves the patient unprotected for a longer period due to once-daily dosing 1

Monitoring After Switch

• No routine coagulation monitoring is required for either agent 1
• Assess renal function, as rivaroxaban has higher renal clearance (35%) compared to apixaban (27%) 1
• Monitor for bleeding complications in the first few weeks after switching 1

Special Populations Requiring Caution

Renal Impairment:

• Rivaroxaban has greater renal dependence than apixaban 1
• Dose adjustment required when CrCl 15-50 mL/min 1
• Avoid if CrCl <15 mL/min 1

Patients on Triple Therapy (anticoagulation + antiplatelet):

• Consider rivaroxaban 15 mg daily instead of 20 mg to reduce bleeding risk when combined with antiplatelet agents 1

Common Pitfalls to Avoid

• Do NOT overlap the two medications—this increases bleeding risk unnecessarily 1
• Do NOT use bridging anticoagulation—both drugs have rapid onset of action 1
• Do NOT forget to counsel about food requirement—rivaroxaban absorption is significantly reduced without food 1
• Do NOT assume equivalent dosing schedules—switching from twice-daily to once-daily requires clear patient education 1

When Laboratory Monitoring May Be Helpful

While routine monitoring is not required, anti-Xa activity measurement may be considered in: 1

• Extreme body weights (BMI ≥50 kg/m²) 2
• Severe renal impairment 1
• Suspected drug accumulation or bleeding complications 1

Note: If measuring anti-Xa levels after switching, wait at least 3 days after stopping apixaban to avoid interference, as residual apixaban can cause overestimation of rivaroxaban levels 1