Direct Oral Anticoagulant — VTE Prophylaxis Post-Surgery Pregnancy: Contraindicated in pregnancy

Rivaroxaban (Perioperative VTE Prophylaxis)

Brand names: Xarelto

Adult dose

Dose: 10 mg once daily (hip/knee arthroplasty VTE prophylaxis)

Route: Oral

Frequency: Once daily

Max: 10 mg/day (VTE prophylaxis)

Hip arthroplasty: 35 days. Knee arthroplasty: 12 days. Start 6-10 hours after surgery (haemostasis achieved). Not approved for general surgical VTE prophylaxis — only orthopaedic

Paediatric dose

Dose: Seek specialist opinion N/A/kg

Route: Oral

Frequency: Seek specialist opinion

Max: Seek specialist opinion

Seek specialist opinion

Dose adjustments

Renal

Avoid if eGFR under 15; use with caution if eGFR 15-29

Hepatic

Contraindicated in hepatic disease associated with coagulopathy

Paediatric weight-based calculator

Patient weight (kg)

Seek specialist opinion

Clinical pearls

Antidote: andexanet alfa (specific reversal agent for factor Xa inhibitors) — approved for major bleeding; also PCC off-label if andexanet alfa not available
NICE TA170 and TA261: rivaroxaban approved for VTE prophylaxis after hip and knee arthroplasty — superior convenience to LMWH (oral, once daily, no injection)
Regional anaesthesia timing: stop rivaroxaban 18 hours before neuraxial block (standard dose); restart no earlier than 6 hours after catheter removal — ESRA guidelines
10 mg VTE prophylaxis dose is NOT interchangeable with treatment doses (15-20 mg) — confusion between doses has caused dosing errors
Extended duration (35 days) for hip arthroplasty: captures the extended VTE risk window post-hip replacement better than shorter LMWH courses

Contraindications

Active clinically significant bleeding
Lesion or condition with significant risk of bleeding
Hepatic disease with coagulopathy
eGFR under 15

Side effects

Bleeding
Nausea
Anaemia
Elevated liver enzymes

Interactions

Antifungals (ketoconazole — significantly increase rivaroxaban levels; avoid)
Strong CYP3A4 + P-gp inducers (rifampicin — reduce levels)
NSAIDs / antiplatelet agents (increased bleeding risk)

Monitoring

Signs of bleeding
Renal function (eGFR) — especially in elderly
Wound haematoma

Reference: BNFc; BNF 90; NICE TA170/TA261; Xarelto SPC; ESRA Neuraxial Anaesthesia and Anticoagulants Guidelines 2021. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

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