Rivaroxaban

NOAs
Rivaroxaban
Dr M.Vejdanparast
MD.Cardiologist
13,Feb,2017

Indicatons
1. Non Valvular Af
2. DVT/PTE
3. Thromboprophylaxis
Dosage
Indication Dosing Recommendations
Atrial Fibrillation 20 mg, Once daily , with evening
DVT & PE
15 mg twice daily with food for 21 days followed by 20 mg once
daily with food
Thromboprophylaxis Knee replacement: 10 mg once daily for 2 weeks
Hip replacement: 10 mg once daily for 5 weeks
M.Vejdanparast 13,Feb,2017

Indicatons
SUPERFICIAL VEIN THROMBOSIS
When?
Superﬁcial thrombus is > 5cm
Within 3-5 cm from spheno-femoral junction
Fondaparinux 2.5 mg SQ daily x 45 days
Enoxaparin 40 mg SQ daily x 45 days
Rivaroxaban 10 mg daily x 45 days

Rivaroxaban

Indicatons
Contraindications
1. GFR < 15
2. Active Bleeding
3. High Risk of Bleeding
4. Chronic Liver Disease
5. Pregnancy
6. Lactation
7. Concomitant Drugs
8. Pediatric

High risk of bleeding
1. Active or recent GI ulceration
2. Presence of malignancy with high risk of bleeding
3. Brain trauma
4. Recent brain,spinal or ophthalmic surgery
5. Recent intracranial bleeding
6. Known or suspected esophageal varices
7. Arteriovenous malformations
8. Vascular aneurysms
9. Intraspinal vascular anomalies or intracerebral

Concomitant Drugs Rvaroxaban
HIV protease inhibitors up to +153%
Ketoconazole; itraconazole; voriconazole; posaconazole; up to +160%
Atorvastatin no effect
Digoxin no effect
Antacids no effect
Verapamil minor effect
Diltiazem minor effect
Amiodarone minor effect
Dronedarone no data yet
Quinidine +50%
Fluconazole +42%
Cyclosporin; tacrolimus +50%
Clarithromycin; erythromycin +30–54%
Rifampicin;  
St John’s wort; carbamezepine; phenytoin; phenobarbital
up to -50%
Red: contraindicated/not recommended Yellow, consider dose reduction if another ‘yellow’

Yellow Factors:
1. Age > 75yr
2. weight < 60kg
3. Concomitant medications
NSAIDs
Systemic Steroids
4. Hx of GIB
5. Recent Surgery on critical organ (Brain & Eye)
6. Thrombocytopenia ( Chemotherapy)
7. HAS BLED >= 3

Indicatons
Contraindications
Other Anticoagulants?
No Yes
Suitable for Rivaroxaban Converting
GFR

Rivaroxaban
Warfarin
• DVT, PE and prevention of recurrence;
stop warfarin and initiate rivaroxaban once INR is ≤2.5.
• Prevention of stroke and systemic embolism
stop warfarin and initiate rivaroxaban once INR ≤3.0.
LMWH
Rivaroxaban 0-2 hours before the time that the next scheduled dose of
LMWH would be due.
Dabigatran Rivaroxaban at the time that the next scheduled dose of dabigatran would
be due
Guidance on converting between anticoagulants

Guidance on converting between anticoagulants

Suitable for Rivaroxaban
Need to Adjustment dose?
1. GFR: 15-49ml/min
2. Two or more:
• Age >= 75yr
• Weight < 60kg
• HASBLED >=3
• Concomitant drugs
Quinidine
Fluconazole
Cyclosporin
Tacrolimus
Clarithromycin
Erythromycin
Rifampicin
Carbamazepine
Phenytoin
Phenobarbital
1. Hypertension
Uncontrolled, >160 mmHg systolic
2. Renal disease
Dialysis, transplant, Cr >2.26 mg/dL
3. Liver disease
Cirrhosis or
bilirubin >2x normal with AST/ALT/AP >3x
normal
4. Stroke history
5. Prior major bleeding or predisposition to
bleeding
6. Labile INR
7. Age > 65
8. Medication usage predisposing to bleeding
Antiplatelet agents, NSAIDs
9. Alcohol or drug usage history
≥ 8 drinks/week
No Yes20mg/dl 15mg/dl

After Administration

Follow-up
Haemoglobin, renal and liver functionYearly
Renal function if CrCl 30–60 ml/min, or > 75 years or fragile
6 monthly 
Renal function If CrCl 15 – 30 ml/min
3 monthly
 
If intercurring condition that may impact renal or hepatic
function
 
On indication

Missed dose
M.Vejdanparast
• Patient can take a forgotten dose up until 12 h after the scheduled intake.
• If that is not possible anymore, the dose should be skipped and the next
scheduled dose should be taken.
Uncertainty about dose intake
Bleeding risk is low (HAS-BLED ≤2) /thrombotic risk is high (CHA2DS2-VASc ≥3):
one could advise to take another pill and then continue the planned dose
Bleeding risk is high (HAS-BLED ≥3) /thrombotic risk is low (CHA2DS2-VASc ≤2):
one could advise to wait until the next scheduled dose.

Overdose without bleeding
Interestingly, as result of limited absorption
Ceiling effect with no further increase in average plasma exposure is expected at
supratherapeutic doses of ≥50 mg Rivaroxaban.
In the case of recent acute ingestion of an overdose, the use of activated charcoal
to reduce absorption may be considered for any NOAC
(with a standard dosing scheme for adults of 30–50 g)

Management of bleeding complications
Non life-threatening bleeding
1. Local hemostatic measures
2. Fluid replacement (colloids if needed)
3. RBC substitution if necessary
4. Platelet substitution (in case of
thrombocytopenia ≤60 × 109/L or thrombopathy)
5. Fresh frozen plasma as plasma expander (not as
reversal agent)
6. Tranexamic acid can be considered as adjuvants
7. Desmopressin can be considered in special cases
(coagulopathy or thrombopathy)
Life-threatening bleeding
1. All of for non life-threatening bleeding
2. Prothrombin complex concentrate (PCC) 25
U/kg (may be repeated once or twice)
500 units/vial
1000 units/vial

Approach Before Surgery

Low Intermediate High
✦ Dental procedures
Up to two tooth extractions
Subgingival scaling
Gingival biopsy
Periodontal surgery
Root canal  
✦ Minor skin procedures
Skin biopsy/Excision  
✦ Cataract extraction/Glaucoma
✦ Endoscopic procedures  
without biopsy
✦ Pacemaker/ICD implantation
✦ Laparoscopic cholecystectomy
✦ Laparoscopic inguinal hernia repair
✦ Other dermatologic procedures
✦ Noncataract ophthalmologic
procedures
✦ Coronary angiography
✦ Other intra-abdominal, intrathoracic,
orthopedic, or vascular surgery
✦ Pacemaker or ICD implantation(ESC)
✦ Any procedure involving neuraxial
anesthesia
✦ Neurosurgery (intracranial or spinal
surgery)
✦ Cardiac surgery (eg, CABG, heart
valve replacement)
✦ Major vascular surgery (eg, aortic
aneurysm repair, aortofemoral bypass)
✦ Major urologic surgery (eg,
prostatectomy, bladder tumor
resection)
✦ Major lower limb orthopedic surgery
(eg, hip/knee joint replacement
surgery)
✦ Lung resection surgery 
Intestinal anastomosis 
✦ Selected procedures (eg, kidney biopsy,
prostate biopsy, cervical cone biopsy,
pericardiocentesis, colonic
polypectomy)
Bleeding Risk

Thromboembolic Risk Mechanical Valve AF VTE
Low
Bileaflet aortic
prosthesis without
CHADS risk factors
CHADS 0–2 without
previous stroke/TIA
VTE >12 mo prior
Intermediate
Bileaflet aortic
prosthesis with
CHADS score of ≥1
CHADS 3-4
• VTE within the past
3–12 mo
• Non severe
thrombophilia
• Recurrent VTE
Active cancer
High
• Any Mitral prosthesis
• Cageball/Tilting
Aortic
• Stroke/TIA in past 6m
• CHADS 5–6
• Previous stroke/TIA
• Rheumatic valvular
heart disease
• VTE within last 3 mo
• Severe thrombophilia
Thromboembolic Risk
Severe thrombophilia includes:
1. Homozygous factor V Leiden
2. prothrombin gene mutation
3. Protein C/S deficiency
4. Antiphospholipid antibodies
M.Vejdanparast

Risk Rivaroxaban Low Risk Bleeding
Intermediate Risk
Bleeding
High Risk
Bleeding
Interruption
•GFR < 50
•GFR 30-50
•GFR 15-30
Continous TX
Continous TX
Continous TX
Skip 1 dose (>24 h)
Skip 1 dose (>24 h)
>36 h
Skip 2 dose
Skip 2 dose
Skip 2 dose
Resumption
Continous TX 24h later
48 - 72h later

Patients undergoing an urgent surgical intervention
Surgery or intervention should be deferred, if possible
until at least 12 h and ideally 24 h after the last dose
If surgery cannot be delayed
the risk of bleeding will be increased and should be weighed against
the urgency of the intervention.

Patients with ACS
1. Primary PCI via a radial approach is strongly recommended over ﬁbrinolysis
2. Recommended to use additional parenteral anticoagulation, regardless of the
timing of the last dose of NOAC
‌‌Bivalirudin might be preferred over UFH or enoxaparin
3. Unless for bail-out situations, glycoprotein IIb/IIIa inhibitors should
generally be avoided
4. If ﬁbrinolysis is the only available reperfusion therapy, it may be considered
if:
dTT, ECT, aPTT (for DTI), or PT not exceeding the upper limit of normal
Additional UFH or enoxaparin should be avoided
(until the NOAC effect has disappeared :12 h or longer after last intake)
ST-elevation myocardial infarction

1. After discontinuing the NOAC and waning of its effect, fondaparinux
(preferred), UFH, or enoxaparin can be initiated.
2. Upstream use of glycoprotein IIb/IIIa inhibitors should be avoided in this
setting.
3. Percutaneous coronary intervention:
Radial approach is preferred
If possible, bare-metal stents (BMSs) are preferred above drug-eluting stents
(DES)
sirolimus- or paclitaxel-eluting stents
Sole balloon angioplasty, or bypass surgery, might also be valid options
4. Periprocedural anticoagulation should be used per local practice:
1. UFH (70 IU/kg) or bivalirudin rather than enoxaparin is preferred
2. UFH should be administered to target ACT or aPTT levels
3. Bivalirudin might be a safer alternative for high-risk patients.
NSTE-ACS
Patients with ACS

Low Risk Bleeding High Risk Bleeding
Low Risk
Thrombosis
TAT:
1m for BMS
6 m for DES
OAC + single antiplatelet : 12 m
TAT:
1m for BMS
High Risk
Thrombosis
TAT:
6 m for BMS
12 m for DES
TAT:
1m for BMS

NOAs Challenges
• Mechanical Prosthetic Valve
• Cancer
• APS
• Emergen Surgery
• Monitoring

Rivaroxaban

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