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Anticoagulants · Hematology

Rivaroxaban

Xarelto®(brand names vary by market)

A once-daily factor Xa inhibitor whose dose depends on what you are treating.

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Illustration of Rivaroxaban as a tabletRIV

Mechanism

Direct, reversible inhibitor of activated factor X: less thrombin generated, without needing antithrombin as an intermediary.

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Indications

  • Stroke prevention in non-valvular atrial fibrillation
  • Treatment and prevention of venous thromboembolism
  • Vascular protection in coronary and peripheral artery disease at low dose

Formulations

Tablet

Dosing concepts

With food

The higher doses need food for reliable absorption; taken on an empty stomach, bioavailability falls enough to matter. This is a counselling point, not a preference.

Indication-specific

Atrial fibrillation, acute VTE treatment, extended VTE prophylaxis and vascular protection all use different doses and schedules. The dose is meaningless without knowing the indication.

Renal function

Contraindicated below a defined creatinine clearance, and the threshold differs by indication.

Concepts, not prescribing instructions. Practice numbers live in current references and local protocols.

Pharmacokinetics

Bioavailability
~66% fasting at higher doses, near-complete with food
Half-life
5 to 9 h, longer in older adults
Elimination
mixed: About one third renal unchanged; the rest hepatic via CYP3A4 and P-glycoprotein
Protein binding
~92%, so it is not dialysable
Play with these concepts in the PK Lab

Adverse effects

  • Bleedingcommon & serious
  • Gastrointestinal bleedingseriousSomewhat more than warfarin in the atrial fibrillation trials.
  • Anemiacommon

Contraindications & precautions

Contraindications

  • Active clinically significant bleeding
  • Mechanical heart valves
  • Moderate to severe mitral stenosis
  • Pregnancy
  • Severe renal impairment (threshold varies by indication)

Precautions

  • Antiplatelet co-therapy
  • Strong CYP3A4 or P-glycoprotein inducers or inhibitors
  • Older adults with falls

Interactions

Monitoring

Renal function

It determines eligibility and dose · Baseline then at least annually, more often if impaired or unwell

Hemoglobin

Occult gastrointestinal loss is the commonest way bleeding presents

Adherence

A once-daily anticoagulant with a nine-hour half-life leaves a real gap after a missed dose

Counselling points

  • Take the treatment doses with your evening meal; food is needed for it to be absorbed properly.
  • Do not skip doses; unlike warfarin there is no reservoir, and protection fades within a day.
  • Tell every dentist, surgeon and pharmacist that you take an anticoagulant.
  • Report black stools, blood in urine, or any head injury however minor.
  • Do not take ibuprofen or naproxen without asking.

Clinical pearls

  • No routine monitoring does not mean no monitoring. Renal function, hemoglobin and adherence are all checkable and all matter.
  • It is not interchangeable with apixaban: dosing schedules, food requirements and renal thresholds all differ, and swapping them on a discharge summary is a real error.
  • There is a specific reversal agent, but availability varies; local protocol should be known before it is needed.

References & review

  • Rivaroxaban product monograph (consult the current version for your market) (monograph)
  • Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed. (reference-work)

Last reviewed 2026-08-16 · jurisdiction: global · drug information changes; verify against current references before practice use.

Keep going

Anticoagulants →Apixaban →The coagulation cascade →Anticoagulation in atrial fibrillation →Compare with another agent →