Equivalent Anticoagulant to Xarelto 20mg for Menorrhagia
Switch from Xarelto (rivaroxaban) 20mg to Eliquis (apixaban) 5mg twice daily, as apixaban has a significantly lower risk of heavy menstrual bleeding compared to rivaroxaban. 1, 2, 3
Evidence for Apixaban as the Preferred Alternative
Apixaban causes substantially less menstrual bleeding than rivaroxaban. In women of reproductive age, rivaroxaban was associated with prolonged menstrual bleeding (27% vs. 8.3%, P = 0.017), increased need for menorrhagia-related medical or surgical intervention (25% vs. 7.7%, P = 0.032), and more adaptations of anticoagulant therapy (15% vs. 1.9%, P = 0.031) compared with vitamin K antagonists. 1
The risk of heavy menstrual bleeding is lower with apixaban than rivaroxaban. Multiple studies confirm that apixaban and dabigatran have lower rates of heavy menstrual bleeding compared to rivaroxaban. 3
Apixaban has superior safety outcomes overall. In a large Medicare study of 581,451 patients, rivaroxaban was associated with increased risk of major hemorrhagic events (7.5 vs 5.9 per 1000 person-years; HR 1.26) and fatal extracranial bleeding (1.4 vs 1.0 per 1000 person-years; HR 1.41) compared to apixaban. 2
Dosing Equivalence
Standard dose apixaban is 5mg twice daily, which is the therapeutic equivalent to rivaroxaban 20mg once daily for atrial fibrillation and venous thromboembolism treatment. 1
Dose reduction to apixaban 2.5mg twice daily is indicated if the patient meets at least 2 of the following criteria: age ≥80 years, weight ≤60kg, or serum creatinine ≥1.5 mg/dL. 1
Switching Protocol
Stop rivaroxaban and start apixaban at the time of the next scheduled rivaroxaban dose. Given rivaroxaban's 8-9 hour half-life, no bridging is required. 1
For patients currently on Eliquis (as mentioned in your context), if they are experiencing menorrhagia, the issue is likely not the anticoagulant choice but rather requires hormonal management (see below), as apixaban is already the preferred agent for minimizing menstrual bleeding. 1, 3
Managing Menorrhagia While on Anticoagulation
First-line hormonal therapy: levonorgestrel intrauterine system, which can result in decreased blood loss and, in some cases, amenorrhea while continuing anticoagulation. 3
Alternative hormonal options include subdermal implants, progesterone-based therapies, or combined hormone therapies, all of which are highly effective for decreasing menstrual blood loss. 3
Evaluate for iron deficiency and anemia at each visit and provide supplementation as needed. 3
Critical Pitfalls to Avoid
Never skip anticoagulant doses to manage menorrhagia, as abbreviating the course of anticoagulation or skipping doses can increase the risk of recurrent venous thromboembolism by as much as fivefold. 3
Do not assume all DOACs cause similar bleeding patterns. Rivaroxaban specifically has higher rates of menorrhagia compared to other DOACs due to its chemical structure and pharmacokinetics. 1, 4, 3
Registry data shows 32% incidence of abnormal uterine bleeding in women of reproductive age on factor Xa inhibitors, so proactive counseling and monitoring during the first cycles after DOAC initiation is essential. 1