Xarelto (Rivaroxaban) Dosing
Rivaroxaban dosing depends on the specific indication, with the most common regimens being 15 mg twice daily for 3 weeks followed by 20 mg once daily for acute VTE treatment, 20 mg once daily for stroke prevention in atrial fibrillation, and 10 mg once daily for VTE prophylaxis after orthopedic surgery. 1
Acute VTE Treatment (DVT/PE)
For acute deep vein thrombosis or pulmonary embolism, start rivaroxaban 15 mg twice daily for the first 3 weeks, then transition to 20 mg once daily for continued treatment. 1, 2
- This single-drug regimen eliminates the need for parenteral heparin bridging and provides immediate anticoagulation within 2-4 hours. 1, 3
- The 15 mg twice-daily initial phase achieves a strong antithrombotic effect during the acute treatment period when thrombotic risk is highest. 4
- After 3 weeks, the 20 mg once-daily maintenance dose balances efficacy against bleeding risk for long-term treatment. 4
Extended VTE Prevention
After completing initial treatment (minimum 3 months), continue rivaroxaban 20 mg once daily indefinitely for unprovoked VTE, with no scheduled stop date. 5
- Extended treatment with 20 mg once daily reduces recurrent VTE from 7.1% to 1.3% compared to placebo. 5
- Major bleeding occurs in only 0.7% of patients annually on extended therapy. 5
- Reassess patients at least annually for continued need, bleeding risk, and patient preferences. 5
Atrial Fibrillation (Stroke Prevention)
For stroke prevention in non-valvular atrial fibrillation, use rivaroxaban 20 mg once daily. 1
- Reduce to 15 mg once daily if creatinine clearance is 30-49 mL/min. 1, 6
- This dose was noninferior to warfarin for preventing stroke/systemic embolism with fewer intracranial and fatal bleeding events. 1
VTE Prophylaxis After Orthopedic Surgery
For prevention of VTE after total hip or knee replacement, use rivaroxaban 10 mg once daily. 1, 7
- Start 6-10 hours after surgery. 1
- Continue for 2 weeks after total knee replacement or 5 weeks after total hip replacement. 1
Coronary Artery Disease/Peripheral Artery Disease
For reduction of major cardiovascular events in CAD or PAD, use rivaroxaban 2.5 mg twice daily in combination with aspirin. 1, 6
Renal Impairment Adjustments
Dose adjustments are critical based on creatinine clearance to prevent drug accumulation and bleeding. 6
- CrCl 30-49 mL/min: Reduce to 15 mg once daily for atrial fibrillation; use standard dosing for VTE treatment but monitor closely. 1, 6
- CrCl 15-29 mL/min: Use 15 mg once daily for VTE treatment; observe closely for bleeding signs. 6
- CrCl <15 mL/min: Avoid rivaroxaban use. 6
- End-stage renal disease on dialysis: Limited data available; 15 mg once daily may be considered for atrial fibrillation but efficacy/safety uncertain. 6
Heparin-Induced Thrombocytopenia (HIT)
For acute HIT with thrombosis, use rivaroxaban 15 mg twice daily for 3 weeks, then 20 mg once daily. 1
- For isolated HIT without thrombosis, use 15 mg twice daily until platelet recovery (≥150 × 10⁹/L), then 20 mg once daily if ongoing anticoagulation indicated. 1
Critical Contraindications
Avoid rivaroxaban in the following situations: 1, 6
- Severe renal failure (CrCl <15 mL/min) 6
- Moderate to severe hepatic impairment (Child-Pugh B or C) or any hepatic disease with coagulopathy 6
- Concomitant use of strong dual CYP3A4 and P-glycoprotein inhibitors (azole antifungals, HIV protease inhibitors) 1, 3
- Pregnancy and breastfeeding 1
Administration Details
- Take with food for doses ≥15 mg to ensure optimal absorption. 6
- No routine coagulation monitoring required; PT and aPTT should not be used to monitor rivaroxaban effect. 1, 5
- Oral bioavailability is 80-100% for the 10 mg dose. 3
Perioperative Management
For high bleeding risk procedures, stop rivaroxaban 3 days before surgery if CrCl >30 mL/min. 1