Rivaroxaban 20 mg Dosing in Renal Impairment
For patients with moderate renal impairment (CrCl 15-49 mL/min), reduce rivaroxaban from 20 mg once daily to 15 mg once daily for both atrial fibrillation and VTE treatment after the initial phase. 1, 2
Standard Dosing by Indication
Atrial Fibrillation
- Standard dose: 20 mg once daily with food for stroke prevention in nonvalvular atrial fibrillation 1, 3
- Renal adjustment: Reduce to 15 mg once daily if CrCl 15-50 mL/min 1, 4
- Avoid use: CrCl <15 mL/min 4
Venous Thromboembolism Treatment
- Initial phase: 15 mg twice daily for 21 days 3, 4, 5
- Maintenance phase: 20 mg once daily thereafter 3, 4
- Renal adjustment: For CrCl 15-49 mL/min, use 15 mg once daily during maintenance phase (after completing the initial 21-day period) 2, 4
- Avoid use: CrCl <15 mL/min 4
VTE Prophylaxis Post-Orthopedic Surgery
- Dose: 10 mg once daily, starting 6-10 hours after surgery once hemostasis established 3, 4
- Duration: 12 days for knee replacement; 35 days for hip replacement 4
- Renal adjustment: No dose reduction needed for CrCl ≥15 mL/min 4
Cardiovascular Risk Reduction (CAD/PAD)
- Dose: 2.5 mg twice daily plus aspirin 75-100 mg once daily 4
- No renal adjustment needed based on CrCl 4
Critical Renal Function Thresholds
Calculate creatinine clearance using actual body weight, not ideal body weight. 4
Monitoring Requirements
- CrCl 30-49 mL/min: Assess renal function 2-3 times per year 2, 6
- CrCl 15-29 mL/min: Observe closely and promptly evaluate any signs of bleeding 4
- CrCl <15 mL/min: Avoid rivaroxaban use 4
Pharmacokinetic Rationale
Approximately one-third of rivaroxaban is cleared renally as unchanged active drug. 2, 7 In patients with moderate renal impairment (CrCl 30-50 mL/min), rivaroxaban exposure increases by 44-64% compared to normal renal function 4, 7. The 15 mg dose in this population achieves similar serum concentrations to 20 mg in patients with normal renal function 1, 4.
High Bleeding Risk Considerations
For patients with moderate renal impairment (CrCl 15-49 mL/min) AND high bleeding risk (HAS-BLED score ≥3), use 15 mg once daily. 2 This is particularly important because:
- Patients ≥75 years have increased gastrointestinal bleeding risk with rivaroxaban 6
- History of GI bleeding, peptic ulcer disease, or prior intracranial hemorrhage increases risk 6
- Concomitant antiplatelet agents, NSAIDs, SNRIs, or SSRIs significantly increase bleeding risk 6
Common Pitfalls to Avoid
Do not use the standard 20 mg maintenance dose in patients with CrCl 30-49 mL/min—this substantially increases bleeding risk. 6 Other critical errors include:
- Failing to calculate CrCl before initiating therapy 6
- Using estimated GFR instead of Cockcroft-Gault CrCl calculation 4
- Not reassessing renal function regularly in at-risk patients 2, 6
- Combining with dual CYP3A4 and P-glycoprotein inhibitors (azole antifungals, protease inhibitors) 7
Administration Details
- With food: Take 15 mg and 20 mg doses with food to optimize absorption 4
- Without food: 10 mg and 2.5 mg doses can be taken with or without food 4
- No routine monitoring: PT and aPTT should not be used to monitor rivaroxaban effect 3
- Onset of action: Rapid anticoagulation within 2-4 hours 7, 8
- Half-life: 7-11 hours in younger patients; 11-13 hours in elderly 7, 9