Rivaroxaban

Oral
Deep vein thrombosis, Pulmonary embolism

Oral
Prophylaxis of stroke and systemic embolism in non-valvular atrial fibrillation

Oral
Prophylaxis of postoperative venous thromboembolism

Oral
Prophylaxis of cardiovascular events in high-risk patients

Prophylaxis of postoperative venous thromboembolism; Prophylaxis of cardiovascular events in high-risk patients:

CrCl (mL/min)	Dosage
<15	Contraindicated.

Deep vein thrombosis; Pulmonary embolism:

CrCl (mL/min)	Dosage
<15	Contraindicated.
15-50	Initially, 15 mg bid for 3 weeks, followed by 20 mg once daily. May reduce maintenance dose to 15 mg once daily if risk of bleeding outweighs risk of recurrence.

Prophylaxis of stroke and systemic embolism in non-valvular atrial fibrillation:

CrCl (mL/min)	Dosage
<15	Contraindicated.
15-50	15 mg once daily.

Moderate to severe (Child-Pugh class B and C): Contraindicated.

10-mg tab: May be taken with or without food.
15- & 20-mg tab: Should be taken with food.

Active pathological bleeding, lesions or conditions at increased risk of major haemorrhage (e.g. recent gastrointestinal ulceration, recent brain or spinal injury or surgery, recent intracranial haemorrhage). Renal impairment (CrCl <15 mL/min) or undergoing dialysis. Moderate to severe hepatic impairment (Child-Pugh Class B and C) or hepatic disease associated with coagulopathy. Pregnancy and lactation. Concomitant use with azole-antimycotics (e.g. ketoconazole) or HIV protease inhibitors (e.g. ritonavir); other anticoagulants such as heparin (e.g. enoxaparin, dalteparin), heparin derivatives (e.g. fondaparinux) or oral anticoagulants (e.g. warfarin, dabigatran, apixaban).

Patient with risks of bleeding (e.g. bacterial endocarditis, congenital or acquired bleeding disorders, vascular retinopathy, uncontrolled severe hypertension, bronchiectasis or history of pulmonary bleeding); significant rheumatic heart disease, prosthetic heart valves. Renal impairment (CrCl 15-50 mg/mL). Avoid abrupt discontinuation in the absence of alternative treatment.

Significant: Bleeding (e.g. as epistaxis, gingival, genitourinary bleeding), anaemia (prolonged use).
Gastrointestinal disorders: Abdominal pain.
Injury, poisoning and procedural complications: Wound secretion.
Investigations: Increased serum transaminases.
Musculoskeletal and connective tissue disorders: Back pain, limb pain.
Nervous system disorders: Dizziness.
Skin and subcutaneous tissue disorders: Pruritus.
Potentially Fatal: Major bleeding, post haemorrhagic anaemia.

This drug may cause syncope and dizziness, if affected, do not drive or operate machinery.

Monitor renal function and CBC prior to initiation of therapy and at least annually; LFT; signs of bleeding.

Symptoms: Haemorrhagic complications. Management: Symptomatic and supportive treatment. Activated charcoal may be given to reduce absorption within 8 hours of ingestion.

Increased risk of bleeding with NSAIDs (e.g. aspirin), antiplatelet agents (e.g. clopidogrel), SSRI, and serotonin-norepinephrine reuptake inhibitors (SNRI). Decreased serum concentration with strong CYP3A4 inducers (e.g. rifampicin, phenytoin, carbamazepine, phenobarbital).
Potentially Fatal: Increased plasma concentration and increased risk of bleeding with CYP3A4 and P-gp inhibitors (e.g. ketoconazole, itraconazole, voriconazole, posaconazole); HIV protease inhibitors (e.g. ritonavir); other anticoagulants such as unfractionated heparin, low molecular weight heparin (e.g. enoxaparin, dalteparin), heparin derivatives (e.g. fondaparinux), oral anticoagulants (e.g. warfarin, dabigatran, apixaban).

Decreased serum concentration with St. John’s wort.

Prolonged clotting in PT, aPTT, HepTest and anti-factor Xa activity.

Description: Rivaroxaban is an anticoagulant which selectively and directly inhibits factor Xa (activated factor X) in both the intrinsic and extrinsic pathways of the blood coagulation cascade thereby, inhibiting thrombin formation and development of thrombi. Factor Xa converts prothrombin to thrombin leading to fibrin clot formation and platelet activation.
Pharmacokinetics:
Absorption: Rapidly absorbed from the gastrointestinal tract. Bioavailability: Approx 80-100%. Time to peak plasma concentration: 2-4 hours.
Distribution: Crosses placenta and enters breastmilk. Volume of distribution: Approx 50 L. Plasma protein binding: Approx 92-95%, mainly to albumin.
Metabolism: Metabolised in the liver by CYP3A4/5 and CYP2J2 via oxidative degradation and hydrolysis.
Excretion: Via urine (66%; approx 36% as unchanged drug, 30% as inactive metabolites); faeces (28%; 7% as unchanged drug, 21% as inactive metabolites). Elimination half-life: 5-9 hours.

Source: National Center for Biotechnology Information. PubChem Database. Rivaroxaban, CID=9875401, https://pubchem.ncbi.nlm.nih.gov/compound/Rivaroxaban (accessed on Jan. 23, 2020)

Store below 30°C.

Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics)

B01AF01 - rivaroxaban ; Belongs to the class of direct factor Xa inhibitors. Used in the treatment of thrombosis.

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