Converting from Eliquis (Apixaban) to Xarelto (Rivaroxaban)
Simply stop Eliquis and start Xarelto at the time of the next scheduled Eliquis dose without any overlap or bridging anticoagulation. 1
Direct Conversion Protocol
The conversion between direct oral anticoagulants (DOACs) like apixaban and rivaroxaban is straightforward because both are factor Xa inhibitors with similar pharmacokinetic profiles:
- Discontinue apixaban at the time of the next scheduled dose 1
- Initiate rivaroxaban at the time when the next apixaban dose would have been due 1
- No bridging therapy with heparin (UFH or LMWH) is required or recommended 1
- No washout period is necessary between stopping one and starting the other 1
Dosing Considerations
For Atrial Fibrillation (Stroke Prevention)
Apixaban standard dose: 5 mg twice daily 1
- Reduced to 2.5 mg twice daily if patient meets ≥2 criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL (133 μmol/L) 1
Rivaroxaban standard dose: 20 mg once daily 1
- Reduced to 15 mg once daily if creatinine clearance 30-49 mL/min 1
For Venous Thromboembolism Treatment
Apixaban: 10 mg twice daily for 7 days, then 5 mg twice daily 1
Rivaroxaban: 15 mg twice daily for 3 weeks, then 20 mg once daily 1
Critical Timing Details
The conversion timing depends on the dosing schedule of apixaban:
- If apixaban is dosed twice daily: Give the first rivaroxaban dose at the time of the next scheduled morning apixaban dose 1
- Avoid overlapping doses to prevent excessive anticoagulation 1
Renal Function Assessment
Before conversion, evaluate creatinine clearance (using Cockcroft-Gault formula) to ensure appropriate dosing of rivaroxaban 1:
- CrCl ≥50 mL/min: Standard rivaroxaban dosing 1
- CrCl 30-49 mL/min: Rivaroxaban 15 mg once daily for atrial fibrillation 1
- CrCl 15-29 mL/min: Rivaroxaban use is not well-studied; consider alternative anticoagulation 1
- CrCl <15 mL/min or dialysis: Rivaroxaban is not recommended 1
Drug Interactions to Review
Both apixaban and rivaroxaban are affected by P-glycoprotein and CYP3A4 inhibitors/inducers 1:
- Strong dual inhibitors (e.g., ketoconazole, ritonavir): May require dose adjustment or alternative anticoagulation 1
- Strong dual inducers (e.g., rifampin, carbamazepine, phenytoin): Avoid concurrent use 1
Common Pitfalls to Avoid
Do not bridge with heparin products during the conversion—this significantly increases bleeding risk without reducing thrombotic risk 1. The French Working Group on Perioperative Hemostasis explicitly states bridging is not needed when switching between DOACs 1.
Do not create a gap between stopping apixaban and starting rivaroxaban, as this leaves the patient unprotected from thromboembolism 1.
Do not overlap doses by giving both medications simultaneously, as this doubles anticoagulation effect and increases bleeding risk 1.
Comparative Safety Considerations
Recent real-world evidence suggests important differences between these agents:
- Bleeding rates: Apixaban is associated with lower rates of major bleeding (12.9 vs 21.9 per 1000 person-years) and gastrointestinal bleeding compared to rivaroxaban 2
- Efficacy: Apixaban showed slightly lower rates of ischemic stroke or systemic embolism (6.6 vs 8.0 per 1000 person-years) compared to rivaroxaban 2
- Mortality: Lower all-cause mortality has been observed with apixaban compared to rivaroxaban in matched cohorts 3, 2
While both agents are effective anticoagulants, the conversion should be clinically justified given apixaban's favorable safety profile in head-to-head comparisons 3, 2.
Monitoring After Conversion
No routine laboratory monitoring is required for either agent 1, 4. However: