xarelto

General information and Dosing

Rivaroxaban

An oral direct factor Xa inhibitor approved for:

  • Stroke prevention in atrial fibrillation (20 mg daily, or 15 mg daily in patients with CrCl 15-50 ml/min)
  • Treatment of DVT/PE (15 mg bid for 21 days, then 20 mg daily)
  • Prevention of DVT/PE following total hip or knee replacement (10 mg daily)

Relevant Clinical Trials

Atrial Fibrillation

DVT/PE Treatment

Hip Replacement

Knee Replacement

Therapeutic monitoring

Rivaroxaban is not intended to be monitored using routine coagulation testing. Its fixed dosing is not intended to be adjusted on the basis of any coagulation laboratory parameter. In certain clinical situations in which the absence of anticoagulant effect induced by rivaroxaban needs to be assured, prothrombin time (PT) and partial thromboplastin time (PTT) can be evaluated and should be normal.

These settings include:

  • To assure appropriate rivaroxaban clearance prior to invasive procedures
  • To assure appropriate rivaroxaban clearance prior to thrombolytic therapy for acute ischemic stroke

NOTE: There is no reliable correlation between elevated PT/PTT and therapeutic effect

Hillarp A et al. Effects of oral direct factor Xa inhibitor rivaroxaban on commonly used coagulation assays. J Thromb Haemost 2011; 9:133-9.

Suggestions for Reversal and Management of Bleeding

There is now an FDA approved reversal agent for apixaban, see andexanet alfa and Guidelines For Reversal of Anticoagulants.

Mild Bleeding

  • Delay next dose or discontinue therapy

Moderate to Severe Bleeding

  • Symptomatic treatment
  • Mechanical compression
  • Surgical intervention
  • Fluid replacement and hemodynamic support
  • Blood product transfusion
  • Oral charcoal (if rivaroxaban administered < 2 hrs prior)
  • NOTE: not dialyzable

Life Threatening Bleeding

  • Measures above
  • Charcoal filtration
  • Last resort:  PCC (Kcentra) and andexanet alfa when this product becomes available

Eerenberg ES et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation 2011; 124: 1573-9