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Factor Xa Inhibitor (DOAC) Pregnancy: Contraindicated — crosses placenta; no antidote in pregnancy

Rivaroxaban (VTE Prophylaxis — Orthopaedic)

Brand names: Xarelto

Adult dose

Dose: THR VTE prophylaxis: 10 mg OD for 35 days. TKR VTE prophylaxis: 10 mg OD for 14 days. Treatment of DVT/PE: 15 mg BD × 3 weeks, then 20 mg OD.
Route: Oral (with food for 15/20 mg doses; 10 mg fasting acceptable)
Frequency: OD or BD (depending on indication)
Max: 20 mg OD (treatment); 10 mg OD (prophylaxis)
RECORD trials: rivaroxaban 10 mg OD superior to enoxaparin for VTE prophylaxis after THR and TKR. Start 6–10h post-surgery. No routine monitoring required.

Paediatric dose

Route: N/A
Frequency: N/A
Max: Not licensed for orthopaedic VTE prophylaxis in children
Not established for orthopaedic VTE prophylaxis in children; paediatric VTE treatment studies available separately (EINSTEIN-Jr)

Dose adjustments

Renal

Avoid if eGFR <15. Treatment: use with caution if eGFR 15–29 (higher bleeding risk). Prophylaxis: avoid if eGFR <30 for perioperative use.

Hepatic

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

Clinical pearls

  • Timing after surgery: start 6–10h post-operatively (confirm haemostasis achieved)
  • RECORD trials: rivaroxaban reduced symptomatic VTE + all-cause mortality vs enoxaparin after THR (2%) vs (3.7%)
  • No routine monitoring: anti-Xa testing available if needed (e.g., suspected overdose, pre-emergency surgery)
  • Reversal: andexanet alfa (Ondexxya) available for life-threatening bleeding

Contraindications

  • Active bleeding
  • Significant renal impairment (eGFR <15 for treatment, <30 for prophylaxis)
  • Hepatic disease with coagulopathy
  • Pregnancy and breastfeeding
  • Concomitant systemic azole antifungals and HIV protease inhibitors (combined P-gp/CYP3A4 inhibitors)

Side effects

  • Bleeding (most significant)
  • Nausea
  • Elevated transaminases
  • Anaemia
  • Wound complications post-surgery

Interactions

  • Strong CYP3A4/P-gp inhibitors (ketoconazole, ritonavir) — avoid
  • Strong CYP3A4/P-gp inducers (rifampicin, carbamazepine) — reduced rivaroxaban levels
  • Aspirin/NSAIDs — increased bleeding risk
  • Other anticoagulants — avoid combination

Monitoring

  • Signs of bleeding (wound, GI, neurological)
  • Renal function (3-monthly for treatment; pre/post-operatively for prophylaxis)
  • Haemoglobin

Reference: BNFc; BNF; RECORD 1–4 Trials; NICE TA170 (THR/TKR VTE prophylaxis). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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