Rivaroxaban Approved! Now How Do We Use It?

Mark J. Alberts, MD


November 11, 2011

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Editor's Note:
In this Medscape Expert Video Commentary, the commentator mistakenly states that rivaroxaban is approved for the "treatment" of deep vein thrombosis (DVT). However, the agent is actually approved for the prophylaxis of DVT in those undergoing knee or hip replacement surgery.

Hello, and welcome to this Medscape stroke update. My name is Mark Alberts, Professor of Neurology and Director of the Stroke Program at Northwestern University and Northwestern Memorial Hospital in Chicago, Illinois. Today I would like to update you about some exciting news.

Just a few days ago, the United States Food and Drug Administration approved rivaroxaban (Xarelto®), for stroke prevention in patients with non-valvular atrial fibrillation. Rivaroxaban is the first anti-Xa inhibitor to be approved for this indication. This agent was approved a while back for the prophylaxis of deep vein thrombosis (DVT) in those undergoing knee or hip replacement surgery, but this is a new indication.

The standard dose is 20 mg per day, and it can be given just once daily. The dose is reduced to 15 mg once daily in those patients who have renal impairment.

Rivaroxaban does have some potential drug interactions, particularly with the anti-fungal agents, with some of the antiviral agents, and with carbamazepine and phenytoin, so caution is advised when using these agents together because it could increase the exposure of rivaroxaban and potentially increase the risk of bleeding.

Furthermore, a black box warning indicates that when rivaroxaban is stopped, patients may have an increased risk of stroke; therefore, clinicians should provide some overlap or early use of another anticoagulation agent to prevent or reduce the risk of ischemic events.

The bottom line is that we now have another new agent, the first in its class, an Xa inhibitor that is as effective as warfarin and probably safer than warfarin, for preventing strokes in patients with atrial fibrillation.

This is very exciting news and we look forward to our experience as clinicians as we use this new agent in patients with atrial fibrillation. Keep in mind that rivaroxaban does not have many of the food and other drug interactions that are present with warfarin, and there is no need for routine monitoring of INR or other coagulation parameters.

This is exciting news. We'll see what happens in the future with even more agents that may be used to prevent stroke in patients with atrial fibrillation. Thank you very much for joining me for this Medscape stroke update.


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