Practical guidance for using rivaroxaban in patients with atrial fibrillation: balancing benefit and risk

Sylvia Haas, Christoph Bode, Bo Norrving, Alexander Gg Turpie, Sylvia Haas, Christoph Bode, Bo Norrving, Alexander Gg Turpie

Abstract

Rivaroxaban is a direct factor Xa inhibitor that is widely available to reduce the risk of stroke or systemic embolism in patients with nonvalvular atrial fibrillation and one or more risk factors for stroke. Rivaroxaban provides practical advantages compared with warfarin and other vitamin K antagonists, including a rapid onset of action, few drug interactions, no dietary interactions, a predictable anticoagulant effect, and no requirement for routine coagulation monitoring. However, questions have emerged relating to the responsible use of rivaroxaban in day-to-day clinical practice, including patient selection, dosing, treatment of patients with renal impairment, conversion from use of vitamin K antagonists to rivaroxaban and vice versa, coagulation tests, and management of patients requiring invasive procedures or experiencing bleeding or an ischemic event. This article provides practical recommendations relating to the use of rivaroxaban in patients with nonvalvular atrial fibrillation, based on clinical trial evidence, relevant guidelines, prescribing information, and the authors' clinical experience.

Keywords: direct factor Xa inhibitor; novel oral anticoagulants; peri-interventional management; practical guidance; rivaroxaban; stroke prevention.

Figures

Figure 1
Figure 1
Algorithm for use of a reduced dose of rivaroxaban (15 mg once daily instead of 20 mg once daily) in patients with nonvalvular atrial fibrillation, according to the patient characteristics. Note: *HAS-BLED bleeding score. Data from Pisters et al. Abbreviations: CrCl, creatinine clearance; Hb, hemoglobin.
Figure 2
Figure 2
(A) Switching from VKAs to rivaroxaban. (B) Switching from rivaroxaban to VKAs. Note: *15 mg od in patients with a CrCI 15–49 mL/min. Abbreviations: CrCl, creatinine clearance; INR, international normalized ratio; od, once daily; VKA, vitamin K antagonist.
Figure 3
Figure 3
Managing patients requiring an invasive procedure or surgery. Abbreviation: PCC, prothrombin complex concentrate.
Figure 4
Figure 4
Management of patients with atrial fibrillation experiencing ischemic stroke. Notes: *Confirmed with a chromogenic anti-factor Xa assay (or PT assay with a rivaroxaban-sensitive reagent, if anti-factor Xa assays are not available); **after confirmation, with neuroimaging, that the risk of hemorrhagic conversion has subsided; †in patients who have controlled blood pressure and a normal platelet count. Abbreviation: PT, prothrombin time.
Figure 5
Figure 5
Assessment of bleeding risk in patients receiving rivaroxaban: anticoagulant-related and patient-related risk factors. Abbreviations: bid, twice daily; NSAID, nonsteroidal anti-inflammatory drug; od, once daily.
Figure 6
Figure 6
Recommended strategies for managing bleeding events. Notes: Rivaroxaban is not dialyzable because of its high plasma protein binding. In patients with mild/local bleeding, the balance between the need to manage a bleeding event and the increased risk of stroke in nonanticoagulated patients should be considered. *Activated charcoal may only be useful to reduce rivaroxaban absorption after overdose if administered shortly after tablet intake. Abbreviations: FFP, fresh frozen plasma; PCC, prothrombin complex concentrate; rFVIIa, recombinant factor VIIa.

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