Rivaroxaban

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

• Bleeding is the principal hazard — avoid in active clinically significant bleeding and in hepatic disease with coagulopathy, and assess bleeding risk before and during treatment; andexanet alfa or prothrombin complex concentrate may be used for life-threatening bleeds.
• Avoid concomitant strong dual inhibitors or inducers of CYP3A4 and P-glycoprotein (such as azole antifungals, certain protease inhibitors, rifampicin), and do not use in pregnancy or breastfeeding.
• Treatment-dose tablets must be taken with food for reliable absorption, and the drug is contraindicated in severe renal impairment with caution as creatinine clearance falls.

Monitoring

Routine coagulation monitoring is not required, but check renal and hepatic function and full blood count periodically and review for signs of bleeding or anaemia.

Counselling the patient

• Take treatment doses with food at the same time each day.
• Report unusual bruising, blood in urine or stool, or prolonged bleeding.
• Carry an anticoagulant alert card and tell any dentist or surgeon.

Evidence & guidelines

Its indications are supported by the ROCKET-AF, EINSTEIN and COMPASS trial programmes and endorsed in NICE technology appraisals.