Rivaroxaban

Aka: Rivaroxaban, Xarelto

1. Mechanism
   1. Oral direct Xa inhibitor
2. Indications
   1. Atrial Fibrillation
      1. Alternative to Warfarin (where PradaxaDyspepsia not tolerated, or twice daily dosing difficult)
      2. Poor INR control on Warfarin
      3. Barriers to INR monitoring
      4. Warfarin Drug Interactions
   2. Deep Vain Thrombosis prophylaxis post-hip or knee replacement
3. Pharmacokinetics
   1. Half-life: 5-9 hours in young patients (11-13 hours in the elderly)
   2. Onset: 1-4 hours post-ingestion
   3. Hepatic excretion
      1. Contrast with Dabigatran which has primarily renal excretion
4. Precautions
   1. No antidote for bleeding
5. Dosing
   1. Taken with evening meal increases absorption
   2. Atrial Fibrillation
      1. Creatinine Clearance >50 ml/minute: 20 mg daily
      2. Creatinine Clearance 15-50 ml/minute: 15 mg daily
         1. Do not use in patients with Creatinine Clearance <15 ml/minute
   3. Deep Vain Thrombosis prophylaxis (hemostasis must be achieved before starting; start 6-10 hours post-op)
      1. Post hip surgery: 10 mg once daily for 35 days
      2. Post knee surgery: 10 mg once daily for 12 days
6. Efficacy
   1. Same efficacy as Warfarin in prevention against thrombotic events (e.g. CVA) in Atrial Fibrillation
7. Disadvantages
   1. Cost: $260/month (contrast with Warfarin which is $80/month with monitoring)
8. Safety
   1. Longterm data is less available than for Warfarin
   2. Fewer intracranial bleeding complications than with Warfarin (Coumadin)
   3. More Gastrointestinal Bleeding complications than with Coumadin
9. References
   1. (2011) Prescr Lett 18(12):67
   2. (2012) Prescr Lett 19(3):13