Treatment Name: Rivaroxaban (Xarelto®)

Rivaroxaban (Xarelto®) is a Supportive Care Therapy to prevent or treat Blood Clots

How does rivaroxaban (Xarelto®) work?
Rivaroxaban is designed to help your body eliminate blood clots by blocking the action of a specific clotting factor known as factor Xa (“factor ten-A”). By blocking clotting factor Xa, your body breaks down the clot faster than it can build it. This is known as “anticoagulation treatment."

Goals of therapy:
Rivaroxaban is taken to prevent or treat blood clots that are harmful to your body, for example, blood clots in the heart, lungs, or brain, or those that cause swelling or pain in the arms or legs.

Rivaroxaban (Xarelto®) is available by doctor's prescription only.

Schedule

Usual rivaroxaban (Xarelto®) starting dose for patients with blood clots:

Rivaroxaban 15 mg oral tablet by mouth Twice Daily with food for the first 21 consecutive days,
then 20 mg oral tablet by mouth Once Daily with food around the same time each day thereafter
- Note: Rivaroxaban is not recommended for treating blood clots in patients with poor kidney function (such as those with CrCl less than 30 mL/min)
- Note: Do NOT stop taking rivaroxaban without first talking to your doctor

It is very important to take each dose of rivaroxaban 15 mg or 20 mg with food as this increases the amount of the drug that is absorbed into blood. Taking 15 mg or 20 mg on an empty stomach decreases absorption and may decrease the effectiveness of rivaroxaban. Of note, the 10 mg tablet may be taken with or without food.

It can take a long time for your body to break down and get rid of a blood clot. Typically, patients with cancer who develop a blood clot are treated with rivaroxaban for 3 to 6 months; however, rivaroxaban therapy may be continued until the cancer is no longer present in the body or your doctor may recommend that it be given indefinitely or lifelong.

Note: Your doctor may choose to shorten or lengthen the amount of time you stay on therapy due to certain factors specific to your case.

Rivaroxaban and surgery:
It is important that you tell your doctors that you are taking rivaroxaban if there is a need for surgery, epidural placement, spinal puncture, or invasive dental procedures before these procedures are performed. If you have taken a dose of rivaroxaban within 24 hours of a planned procedure, your doctors may decide it is safest to reschedule.

If surgery is needed and anticoagulation needs to be discontinued, rivaroxaban should be stopped at least 24 hours prior to the surgery to decrease the risk of bleeding, or as directed by your doctor. Rivaroxaban should then be restarted after surgery when your doctor tells you that it is safe to do so.

Changing between anticoagulants - Always ask your doctor or pharmacist for detailed instructions:

When switching from rivaroxaban to warfarin, it is recommended to discontinue warfarin and begin taking rivaroxaban when the International Normalized Ratio (INR) is below 3 to ensure adequate anticoagulant coverage
When switching from an injectable anticoagulant such as enoxaparin or dalteparin, start rivaroxaban 0 to 2 hours before the next scheduled administration of the injectable anticoagulant. Do NOT take both medications as this would increase the risk of bleeding

Side Effects

In the prescribing label information (rivaroxaban package insert), the most commonly reported side effects from rivaroxaban (Xarelto®) are shown here. The exact percentages of patients that will experience rivaroxaban side effects is unknown because it has been used under widely varying patient populations in a variety of clinical trials:

Important note: Report any unusual bruising or bleeding to your doctor. If injured, it might take longer than usual to stop bleeding.

*In clinical trials, 28% of patients had a bleeding event that was considered minor, 9% had a non-major bleeding event, but required hospitalization or evaluation by a doctor, and 1% had a bleed that was considered a major or life-threatening bleeding event.

Rivaroxaban should be used in pregnant women only if the potential benefits to the mother outweigh the potential risks to the unborn baby. Women should not nurse babies while taking rivaroxaban as it is unknown if rivaroxaban enters the mother’s milk.

Side effect videos
BleedingBlood Clots

Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before treatment and periodically during treatment until stable. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), or basic metabolic panel (BMP), plus any others your doctor may order. This helps to assess number of red blood cells at baseline (in case of a bleed) and kidney function (used to ensure safe dosing of rivaroxaban).

If you are a woman of child-bearing potential, your doctor may recommend a pregnancy test before starting rivaroxaban therapy.

How often is imaging needed?
Imaging is checked before treatment to diagnose the presence of a blood clot. Imaging may include: computerized tomography angiography (CT angiogram or CTA) scans, ventilation/perfusion (VQ) scan, or ultrasounds of arms or legs (also known as a “venous doppler”).

Typically, if a blood clot is found on any of the above imaging techniques, the scan is not routinely repeated after starting therapy to see if the blood clot has gone away. Other imaging such as magnetic resonance imaging (MRI) or computerized tomography (CT) scans may be checked during treatment if there is a concern for bleeding into certain organs or tissues.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue rivaroxaban as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy. If you are a woman taking rivaroxaban, inform your doctor immediately if you intend to become pregnant or become pregnant to discuss pregnancy planning.

Questions to Ask Your...

A better understanding of your treatments will allow you to ask more questions of your healthcare team. We then hope that with the answers, you will get better results and have greater satisfaction with your care. Because we know it's not always easy to know what questions to ask, we've tried to make it easy for you!

Choose any healthcare provider below to see common questions that you may want to ask of this person. Then, either print each list to bring to your clinic visits, or copy the questions and send them as a message to your healthcare team through your electronic medical record.

Questions to ask your Doctor Nurse Pharmacist

Questions to ask your Nurse Doctor Pharmacist

Questions to ask your Pharmacist Doctor Nurse

ChemoExperts Tips

May interact with certain antifungal, antiviral, seizure medications, herbal medications, antidepressants known as SSRIs or SNRIs, or others. When these medications are taken with rivaroxaban, they can either increase the blood levels of rivaroxaban and increase risk of bleeding or decrease blood levels and decrease the effectiveness of rivaroxaban. A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
You may bruise more easily and it may take longer to stop bleeding from simple cuts and scrapes
Rivaroxaban may need to be temporarily held before and after any surgeries or procedures, or if your platelet count is too low to reduce the risk of bleeding
Tell your doctor if you have a known bleeding disorder before you start treatment with rivaroxaban
If you have trouble swallowing rivaroxaban tablets, they may be crushed and mixed with applesauce and eaten immediately. This should be followed by food as well
Talk to your doctor or pharmacist before taking any over-the-counter pain medications such as ibuprofen, naproxen, and aspirin as these medications can increase the risk of major bleeding when taken with rivaroxaban, even at low doses
If you miss a dose, take the missed dose IMMEDIATELY if it is the same day. If you are taking rivaroxaban twice daily, you can take two tablets at the same time to make up for the missed dose if needed. Resume the normal dosing schedule the following day
Rivaroxaban is supplied as 10 mg tabs, 15 mg tabs, 20 mg tabs, as well as a 30-day starter pack consisting of both 15 mg and 20 mg tabs for the initial treatment of a blood clot in the vein or lung
Rivaroxaban should be stored at room temperature (59°F – 86°F)

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for Rivaroxaban (Xarelto®), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for Rivaroxaban (Xarelto®). Depending upon your income, they may be able to help cover the cost of:

Rivaroxaban (Xarelto®)

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as Rivaroxaban (Xarelto®) and are the best source to help you understand drug cost.

Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

References

1) Prins MH, Lensing AW, Brighton TA, et al. Oral rivaroxaban versus enoxaparin with vitamin K antagonist for the treatment of symptomatic venous thromboembolism in patients with cancer (EINSTEIN-DVT and EINSTEIN-PE): a pooled subgroup analysis of two randomised controlled trials. Lancet Haematol. 2014 Oct;1(1):e37-46.

Created: July 10, 2017 Updated: October 24, 2018

What is Blood Clots?

To stop bleeding when an injury occurs, platelets along with a complex system of proteins called the "coagulation cascade," are activated to start the formation of blood clots when an injury occurs.

Cancer can cause the coagulation cascade to be active even when there is no injury present. These clots most commonly form in the large veins of the arms or legs (deep vein thrombosis) and can break off and travel to the lungs (pulmonary embolism), heart (myocardial infarction), or brain (thrombotic stroke).

Medications can decrease the risk of a harmful clot from forming. When an unwanted blood clot does form, medications need to be given to stop the clot from getting bigger while your body breaks down the existing clot. These medications either slow down the activity of proteins in the coagulation cascade or decrease the amount of clotting factor proteins in the blood.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status, 2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

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Citalopram (Celexa®)
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Fluoxetine (Prozac®)
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Desvenlafaxine (Pristiq®)
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