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Direct Oral Anticoagulant (Factor Xa Inhibitor) Pregnancy: D

Rivaroxaban

Brand names: Xarelto

Adult dose

Dose: 15 mg BD × 21 days then 20 mg once daily (VTE treatment); 10 mg once daily (prophylaxis)
Route: oral
Frequency: varies by indication
Max: 20 mg/day (treatment); 10 mg/day (prophylaxis)
Take 15/20 mg doses with food (increases absorption); 10 mg can be taken without food; no routine monitoring required

Paediatric dose

Route: oral
Frequency: varies
Max: Weight-based (see SPC)
Concentration: granules for suspension mg/ml
Licensed in children ≥2 years for VTE treatment/prevention; dose based on body weight bands — use granules (1 mg/mL) below 12 years

Dose adjustments

Renal

Reduce to 15 mg OD for AF if eGFR 15–49 ml/min; avoid if eGFR <15 ml/min

Hepatic

Avoid in severe hepatic disease (Child-Pugh B/C with coagulopathy)

Clinical pearls

  • Reversal agent: andexanet alfa (approved) or 4-factor PCC if unavailable
  • EINSTEIN trials: non-inferior to LMWH/warfarin for VTE with similar bleeding
  • No bridging required for elective procedures — usually hold 24–48h pre-procedure

Contraindications

  • Significant bleeding risk
  • Severe hepatic impairment with coagulopathy
  • eGFR <15 ml/min
  • Prosthetic heart valves

Side effects

  • Bleeding (GI most common)
  • Anaemia
  • Nausea
  • Elevated LFTs
  • Bruising

Interactions

  • Strong CYP3A4 and P-gp inhibitors (azole antifungals, HIV PIs — avoid)
  • Strong inducers (rifampicin — avoid)
  • NSAIDs/antiplatelets (bleeding risk)

Monitoring

  • No routine coagulation monitoring needed
  • Renal function annually
  • FBC (signs of bleeding)

Reference: BNFc; BNF 86; NICE TA354; EINSTEIN trials. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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