Is it safe to continue Rivaroxaban therapy in a patient with Atrial Fibrillation, who is also taking Fluticasone Propionate + Salmeterol, Semaglutide, Tibolone, Flecainide, Atorvastatin, and Dapagliflozin, with no reported changes in condition or side effects and stable blood tests and check-ups?

Rivaroxaban Continuation is Safe and Appropriate

Yes, it is safe to continue rivaroxaban therapy in this patient with atrial fibrillation who is stable on current medications with no reported side effects or changes in condition. 1

Primary Recommendation

Continue rivaroxaban at the current prescribed dose for stroke prevention in atrial fibrillation, as DOACs like rivaroxaban are the preferred anticoagulation strategy for nonvalvular atrial fibrillation. 1, 2

• Rivaroxaban has demonstrated noninferiority to warfarin for stroke prevention (1.7% vs 2.2% per year) with significantly reduced intracranial hemorrhage (0.5% vs 0.7%) and fatal bleeding (0.2% vs 0.5%). 3
• The American College of Cardiology recommends DOACs over warfarin as first-line therapy for atrial fibrillation patients without mechanical heart valves or moderate-to-severe mitral stenosis. 1

Drug Interaction Assessment

The patient's current medication regimen shows no clinically significant interactions that would contraindicate rivaroxaban continuation:

• Flecainide + Rivaroxaban: This combination is explicitly supported by guidelines, as flecainide is a recommended antiarrhythmic for rhythm control in atrial fibrillation patients requiring anticoagulation. 1
• Atorvastatin: No significant interaction with rivaroxaban; statins are routinely co-prescribed with anticoagulants. 1
• Fluticasone/Salmeterol: No interaction with rivaroxaban; inhaled corticosteroids do not affect anticoagulation. 4
• Semaglutide: No direct interaction with rivaroxaban; GLP-1 agonists are safe with anticoagulation therapy. 5
• Dapagliflozin: No interaction with rivaroxaban; SGLT2 inhibitors do not affect anticoagulation. 4
• Tibolone: While hormone therapy can theoretically affect thrombotic risk, there is no contraindication to concurrent rivaroxaban use when appropriately indicated for atrial fibrillation. 4

Essential Monitoring Requirements

Ensure the following assessments are current or scheduled:

• Renal function monitoring: Check creatinine clearance at least annually to confirm appropriate rivaroxaban dosing (20 mg daily for CrCl >50 mL/min; 15 mg daily for CrCl 30-49 mL/min). 1, 4
• Hepatic function: Verify liver function tests are stable, as advanced liver disease contraindicates DOAC use. 2
• Bleeding risk assessment: Confirm HAS-BLED score has been calculated and modifiable bleeding risk factors are addressed. 1

Dosing Verification

Confirm the patient is receiving the correct rivaroxaban dose based on renal function:

• Standard dose is 20 mg once daily for patients with CrCl >50 mL/min. 4
• Reduced dose of 15 mg once daily is required for CrCl 30-49 mL/min. 4
• Rivaroxaban is contraindicated if CrCl <30 mL/min (except in specific circumstances). 2

Critical Safety Considerations

Address these potential pitfalls during the telehealth visit:

• Medication adherence: Rivaroxaban requires once-daily dosing with the evening meal for optimal absorption; confirm the patient takes it consistently at the same time. 4
• Missed dose protocol: If a dose is missed, it should be taken as soon as remembered on the same day; do not double the next dose. 4
• Bleeding precautions: Reinforce warning signs of serious bleeding (unusual bruising, blood in urine/stool, severe headache, prolonged bleeding from cuts). 4
• No routine coagulation monitoring needed: Unlike warfarin, rivaroxaban does not require INR checks, but this does not eliminate the need for periodic clinical assessment. 2

Contraindications to Rule Out

Verify the patient does NOT have any absolute contraindications:

• Mechanical heart valve (rivaroxaban is contraindicated; warfarin required). 1, 2
• Moderate-to-severe mitral stenosis (rivaroxaban contraindicated; warfarin required). 1, 2
• Active pathological bleeding. 4
• Severe hepatic impairment with coagulopathy. 2

Refill Authorization

Approve the rivaroxaban refill with documentation of:

• Current CHA2DS2-VASc score justifying anticoagulation (should be ≥1 for males, ≥2 for females). 1
• Most recent creatinine clearance value and date. 4
• Confirmation of no new bleeding events or concerning symptoms. 4
• Patient understanding of medication purpose and bleeding precautions. 4