Rivaroxaban is a direct oral anticoagulant (DOAC) that selectively inhibits Factor Xa, a key enzyme in the coagulation cascade. By blocking Factor Xa activity, rivaroxaban interrupts thrombin generation and prevents clot formation. It has become a widely used alternative to traditional vitamin K antagonists (VKAs) such as warfarin, offering predictable pharmacokinetics, fewer food interactions, and no routine monitoring for most patients. Approved in both the EU and US in the late 2000s, rivaroxaban is now prescribed globally for a variety of thromboembolic disorders.
It is available in several strengths (2.5 mg, 10 mg, 15 mg, and 20 mg tablets) and has flexible dosing regimens tailored to indications. Rivaroxaban is absorbed quickly, with peak plasma concentrations within 2–4 hours, and has a half-life of 5–13 hours depending on age and kidney function. Its dual elimination pathways (two-thirds metabolized by the liver, one-third excreted unchanged by the kidneys) reduce the dependency on a single organ system for clearance, though impairment in either organ can significantly impact drug exposure.
Unlike VKAs, rivaroxaban does not require regular INR monitoring, but clinical vigilance is still essential due to its bleeding risk. Patients must be educated about adherence because missing even a single dose can increase thrombotic risk. Rivaroxaban has simplified anticoagulation management in clinical practice, but careful selection and monitoring remain necessary, particularly in populations at higher bleeding risk.
Adherence is critical. Missed doses increase risk of clot formation. Patients should be encouraged to take rivaroxaban at the same time each day, preferably with food to optimise absorption for higher doses.
Because rivaroxaban affects clotting, even small injuries may cause prolonged bleeding. Patients should be counselled on what to do if they experience nosebleeds lasting >10 minutes, visible blood in urine or stool, or unexplained swelling/pain that could indicate a clot or bleed.
Patient education about signs of bleeding, adherence importance, and communication with healthcare providers before new prescriptions or procedures is vital.
Patients should always provide a full list of medications, including over-the-counter pain relievers, supplements, and herbal remedies. Pharmacist review of new prescriptions is strongly advised.
Overdose: Symptoms include excessive or uncontrolled bleeding. Activated charcoal may reduce absorption if administered quickly after ingestion. Specific reversal agents such as andexanet alfa (in some countries) or prothrombin complex concentrates may be used in life-threatening bleeds.
Accidental double dose: Increases bleeding risk. Patients should contact a healthcare professional and monitor closely for symptoms such as prolonged nosebleeds, dark stools, or unusual bruising.
Missed dose: If on once-daily regimen, take as soon as remembered the same day; do not double up the next day. If on a twice-daily regimen (e.g., initial DVT treatment), take both 15 mg tablets together if remembered the same day, then continue as prescribed the next day.
Patients should be instructed to always follow their prescription label and seek immediate help if they experience uncontrolled bleeding, severe headache, or signs of stroke.
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