Rivaroxaban (Stroke Prevention — AF)

How it works

It directly and reversibly inhibits activated factor Xa, interrupting the coagulation cascade and reducing thrombin generation and clot formation.

Prescribing in practice

• It is contraindicated in active clinically significant bleeding and should be avoided in mechanical heart valves and moderate-to-severe mitral stenosis, where it is not a substitute for a vitamin K antagonist.
• Dose is adjusted according to renal function, and it should be taken with food at the treatment-dose level to ensure adequate absorption.
• Concomitant strong dual CYP3A4 and P-glycoprotein inhibitors or inducers, and other antithrombotics, materially alter bleeding risk and should prompt review.

Monitoring

Routine coagulation monitoring is not required, but renal function, haemoglobin and signs of bleeding should be reviewed periodically and before significant procedures.

Counselling the patient

• Take it at the same time each day and report any unusual bruising, blood in urine or stool, or black stools promptly.
• Do not stop it abruptly without advice, as this raises stroke risk.
• Carry an anticoagulant alert card and tell any dentist or surgeon before procedures.

Evidence & guidelines

The ROCKET-AF trial established rivaroxaban as non-inferior to warfarin for stroke prevention in atrial fibrillation, and NICE supports its use in this indication.