Understanding
Rivaroxaban:
An Overview
Contents
- Anticoagulants and their Importance
- Coagulation Cascade and Anticoagulants
- Rivaroxaban
- DOACs compared to Warfarin and
Heparin
- Evidence-based medicine
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Anticoagulants and their
Importance
• Coagulation is a natural response to prevent
excessive bleeding.
• Imbalance can lead to conditions like DVT & PE
• Anticoagulants prevent and treat blood clot
formation.
• Anticoagulants inhibit coagulation cascade
components.
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Rivaroxaban
• Rivaroxaban: direct oral anticoagulant (DOAC).
• Targets Factor Xa in coagulation cascade.
• Disrupts clotting process by inhibiting thrombin
and fibrin formation.
• Predictable, convenient alternative to warfarin and
heparin.
• Fixed doses, no routine monitoring, oral
administration.
• Rapid onset of action, immediate anticoagulation
effect. 6
Rivaroxaban’s
Indications
• Lower or upper extremity DVT, right atrial thrombosis,
pulmonary embolism, catheter related thrombosis
• Cerebral vein and sinus venous thrombosis
• Portal vein thrombosis
• Renal vein thrombosis
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Risks and Considerations
• Renal failure/ severe impairment
• Platelet count <50x 109/L
• Active bleeding/ high risk for bleeding
• Concomitant use of inhibitors or inducers
of CYP3A4
• Childbearing potential without proper
counselling contraceptive measures
• Pregnancy and lactation
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Highlights
• Not recommended in children aged ≥1 year with moderate or
severe renal impairment (GFR <50ml/min/1.73m2)
• And in children aged <1 year with serum creatinine results
above 97.5th percentile
• If a dose is missed the patient should take it immediately.
• Dose should not be doubled within the same day to make up
for a missed dose.
• Xarelto 15mg and 20mg must be taken with food.
• Not been studied in patients with prosthetic heart valves.
• Administer at the time of discontinuing IV Heparin after 5
9
days of Heparinisation & stable oral intake.
Aspect Heparin Warfarin DOACs (e.g., Rivaroxaban)
Directly inhibits Factor Xa
Binds to antithrombin, inhibits thrombin and Inhibits vitamin K epoxide reductase,
Mechanism (Rivaroxaban) or thrombin (other
Factor Xa affecting multiple clotting factors
DOACs)
Administration Intravenous or subcutaneous injection Oral administration Oral administration
Activated Partial Thromboplastin Time (aPTT) for
International Normalized Ratio (INR)
Monitoring unfractionated heparin; Antifactor Xa activity for Limited to no routine monitoring
monitoring
low-molecular-weight heparin
Variable dosing based on weight and aPTT
Dosing Individualized dosing, requires adjustments Fixed doses in many cases
results
Onset of Action Rapid onset Slow onset Rapid onset
Andexanet alfa for Factor Xa
Antidote Protamine sulfate Vitamin K
inhibitors
Extensive potential for drug and food
Interactions Moderate potential for drug interactions Fewer potential interactions
interactions
Idarucizumab (for Dabigatran),
Vitamin K, Fresh Frozen Plasma for rapid
Reversal Agent Protamine sulfate Andexanet alfa (for Factor Xa
reversal
inhibitors)
Atrial fibrillation, DVT, PE, stroke
Indications Acute thromboembolic events, prophylaxis Prevention and treatment of thrombosis
prevention
Rapid onset, short half-life, suitability for Predictable dosing, fewer
Advantages Wide availability, long history of use
hospitalized patients interactions, no routine monitoring
Complex dosing, multiple interactions, Potential cost, limited long-term
Disadvantages Requires injections, frequent monitoring
slower reversal safety data 10
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