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Direct oral anticoagulant (DOAC) — Factor Xa inhibitor Pregnancy: Contraindicated — no data on fetal safety; LMWH is the anticoagulant of choice in pregnancy.

Rivaroxaban

Brand names: Xarelto

Adult dose

Dose: AF (stroke prevention): 20 mg once daily with evening meal; VTE treatment: 15 mg BD for 21 days then 20 mg OD
Route: Oral (with food — improves absorption, especially >10 mg doses)
Frequency: Once daily (AF/VTE maintenance); twice daily (VTE initial 21 days)
Max: 20 mg once daily
AF: 20 mg OD with evening meal (15 mg OD if eGFR 15–49). VTE: 15 mg BD with food for 21 days, then 20 mg OD with food. Post-orthopaedic thromboprophylaxis: 10 mg OD for 14–35 days. Reversal: andexanet alfa (expensive, limited availability) or 4-factor PCC.

Paediatric dose

Route: Oral
Frequency: Twice daily
Max: Weight and indication specific
Paediatric VTE (≥2 years, EINSTEIN-Jr): weight-based dosing. Body weight-based equivalents to adult doses used. Specialist haematology guidance required.

Dose adjustments

Renal

AF: reduce to 15 mg OD if eGFR 15–49. Avoid if eGFR <15. VTE: avoid if eGFR <30.

Hepatic

Avoid in moderate-severe hepatic impairment (Child-Pugh B/C).

Clinical pearls

  • Meals essential with doses ≥10 mg (bioavailability doubles with food)
  • GI bleeding risk higher than apixaban — consider apixaban for patients with prior GI bleed
  • Anti-Xa assay can measure levels if needed (not routine)
  • Perioperative management: stop 24h before (low bleeding risk) or 48h before (high bleeding risk) procedure
  • Reversal: andexanet alfa (AnexXa) licensed but expensive; 4-factor PCC (Octaplex/Beriplex) if andexanet unavailable

Contraindications

  • Active significant bleeding
  • Lesion at risk of clinically significant bleeding
  • Hepatic disease with coagulopathy
  • Pregnancy

Side effects

  • Bleeding (all sites — GI most common with rivaroxaban)
  • Anaemia
  • Nausea
  • Elevated liver enzymes
  • Skin reactions

Interactions

  • Strong CYP3A4 and P-gp inhibitors (ketoconazole, ritonavir) — significantly increase rivaroxaban levels (avoid)
  • Strong CYP3A4 and P-gp inducers (rifampicin, carbamazepine, phenytoin) — significantly reduce levels (avoid)
  • Other anticoagulants and antiplatelet drugs — increased bleeding risk
  • NSAIDs — increased GI bleeding risk

Monitoring

  • eGFR and LFTs annually
  • Signs of bleeding
  • Compliance (twice-daily dosing adherence check)
  • Haemoglobin

Reference: BNFc; BNF; NICE NG196; EINSTEIN trials; ROCKET-AF trial. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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