How to Transition from Eliquis (Apixaban) to Xarelto (Rivaroxaban)
Stop apixaban and start rivaroxaban at the time of the next scheduled apixaban dose—no washout period is required. 1
Transition Protocol
The FDA-approved method is straightforward: discontinue apixaban and administer the first dose of rivaroxaban 0–2 hours before the next scheduled apixaban dose would have been due, then omit the apixaban dose entirely. 1 This approach leverages the short half-lives of both agents (apixaban ≈7–8 hours, rivaroxaban ≈5–9 hours) to maintain continuous anticoagulation without creating a dangerous gap or excessive overlap. 2
Step-by-Step Algorithm
Identify the indication (atrial fibrillation vs. venous thromboembolism) because rivaroxaban dosing differs by indication. 2
Calculate creatinine clearance using the Cockcroft-Gault equation with actual body weight—this is mandatory for proper rivaroxaban dosing. 2
Stop apixaban after the last scheduled dose.
Start rivaroxaban at the time the next apixaban dose would have been given (or up to 2 hours earlier). 1
Select the correct rivaroxaban dose based on indication and renal function (see below). 2, 1
Rivaroxaban Dosing by Indication
For Atrial Fibrillation (Stroke Prevention)
- CrCl >50 mL/min: Rivaroxaban 20 mg once daily with the evening meal. 2, 1
- CrCl 15–50 mL/min: Rivaroxaban 15 mg once daily with the evening meal. 2, 1
- CrCl <15 mL/min or dialysis: Avoid rivaroxaban; consider continuing apixaban or switching to warfarin. 2
Critical point: Rivaroxaban for atrial fibrillation must be taken with food to ensure adequate absorption—this is non-negotiable. 1
For Venous Thromboembolism (Treatment)
If the patient is within the first 21 days of VTE treatment:
- Days 1–21: Rivaroxaban 15 mg twice daily with food. 2, 1
- Day 22 onward: Rivaroxaban 20 mg once daily with food (15 mg once daily if CrCl 15–50 mL/min). 2, 1
If the patient has already completed >21 days of VTE treatment:
Important nuance: The VTE treatment dose of rivaroxaban is 20 mg daily, not the 15 mg dose sometimes used in dual-pathway studies—use the VTE-specific dosing. 2
Key Differences Between Apixaban and Rivaroxaban
Renal Clearance
- Apixaban: Only 27% renal clearance, making it safer in moderate-to-severe renal impairment. 3
- Rivaroxaban: 35–66% renal clearance, requiring dose reduction when CrCl falls below 50 mL/min for atrial fibrillation. 2, 3
This means: If your patient has CrCl 30–50 mL/min and was on apixaban 5 mg twice daily (standard dose), they will need rivaroxaban 15 mg once daily—a mandatory dose reduction that did not apply to apixaban. 2, 3
Food Requirements
- Apixaban: Can be taken with or without food. 3
- Rivaroxaban: The 15 mg and 20 mg doses must be taken with food to ensure adequate absorption; the 10 mg dose can be taken without food. 1
Bleeding Risk
Post-marketing surveillance data suggest rivaroxaban may have a higher reporting rate of hemorrhagic events compared to apixaban, with a reporting odds ratio of 1.58 for rivaroxaban versus dabigatran, while apixaban had a reporting odds ratio of 0.47 versus dabigatran. 4 While this does not prove causation, clinicians should monitor closely after the switch, particularly for gastrointestinal bleeding. 4
Common Pitfalls to Avoid
Do not use the "2-of-3" apixaban dose-reduction criteria for rivaroxaban. Apixaban's dose reduction (to 2.5 mg twice daily) requires ≥2 of: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 3 Rivaroxaban dosing is based solely on creatinine clearance and indication—age and weight do not trigger dose adjustments. 2, 1
Do not forget the food requirement. Rivaroxaban 15 mg and 20 mg tablets have significantly reduced absorption when taken on an empty stomach, potentially leading to subtherapeutic anticoagulation and thrombotic events. 1
Do not use eGFR for rivaroxaban dosing. The FDA label and clinical trials used Cockcroft-Gault creatinine clearance, not eGFR—these are not interchangeable and using eGFR can lead to dosing errors. 2, 3
Do not bridge with parenteral anticoagulation. The direct switch from apixaban to rivaroxaban does not require heparin or enoxaparin bridging—this only increases bleeding risk without benefit. 2, 1
Special Considerations
If the Patient Was on Reduced-Dose Apixaban (2.5 mg Twice Daily)
Determine why the dose was reduced:
If due to severe renal impairment (CrCl 15–29 mL/min): Use rivaroxaban 15 mg once daily with food, but recognize that rivaroxaban has higher renal clearance and may be less safe than continuing apixaban. 2, 3
If due to meeting ≥2 apixaban dose-reduction criteria but CrCl >50 mL/min: Use standard rivaroxaban dosing (20 mg once daily for atrial fibrillation, or the VTE regimen as appropriate) because rivaroxaban does not have age/weight-based dose reductions. 2, 1
If Switching for Bleeding Concerns
Reconsider the switch. Apixaban has demonstrated lower rates of major bleeding (31% reduction) and intracranial hemorrhage (49% reduction) compared to warfarin in the ARISTOTLE trial, and post-marketing data suggest it may have a more favorable bleeding profile than rivaroxaban. 3, 4, 5 If the patient experienced bleeding on apixaban, switching to rivaroxaban may not reduce bleeding risk and could potentially increase it. 4
Monitoring After the Switch
Renal function: Reassess CrCl at least annually, or every 3–6 months if CrCl <60 mL/min, because rivaroxaban's higher renal dependence makes dose adjustments more likely as kidney function changes. 2, 3
Bleeding symptoms: Educate the patient to report any unusual bruising, bleeding gums, blood in urine or stool, or prolonged bleeding from cuts—rivaroxaban may carry higher gastrointestinal bleeding risk. 4
Adherence to food requirement: Confirm at follow-up that the patient is taking rivaroxaban with food, as non-adherence to this requirement is a common cause of treatment failure. 1