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TREATMENT CONSIDERATIONS WHILE TAKING XARELTO®

Switching to or from XARELTO®

FROM WARFARIN

Stop warfarin and start XARELTO® when INR is <3.0

FROM UNFRACTIONATED HEPARIN

Stop the infusion and start XARELTO® at the same time

FROM OTHER ANTICOAGULANTS

Start XARELTO® 0 to 2 hours prior to the next scheduled evening administration of the other anticoagulant

TO WARFARIN*

One approach is to stop XARELTO® and start parenteral anticoagulant and warfarin at time of next scheduled XARELTO® dose

TO OTHER ANTICOAGULANTS†

Stop XARELTO® and start other anticoagulant when the next dose of XARELTO® would have been given

◇For VTE prophylaxis in acutely ill medical patients at risk for thromboembolic complications who are not at high risk of bleeding.

*No clinical trial data are available to guide converting patients from XARELTO® to warfarin. XARELTO® affects INR, so INR measurements made during coadministration with warfarin may not be useful for determining the appropriate dose of warfarin.

†Oral or parenteral rapid-onset anticoagulants.

BLEED MANAGEMENT CONSIDERATIONS IN PATIENTS TAKING XARELTO®

  • Promptly evaluate any signs and symptoms of blood loss and consider the need for blood replacement
  • Discontinue XARELTO® in patients with active pathological hemorrhage
  • An agent to reverse the anti-factor Xa activity of rivaroxaban is available
  • Partial reversal of prothrombin time prolongation has been seen after administration of PCCs in healthy volunteers
  • The use of other procoagulant reversal agents like aPCC or rFVIIa has not been evaluated

This is not intended to replace clinical judgment or determine individual patient care.

Temporary discontinuation for surgery and other procedures

If XARELTO® must be discontinued for a procedure, follow these guidelines:

Before procedure:
  • Stop XARELTO® at least 24 hours before the procedure
  • In deciding whether a procedure should be delayed until 24 hours after the last dose of XARELTO®, the increased risk of bleeding should be weighed against the urgency of intervention
After procedure:
  • Restart XARELTO® as soon as adequate hemostasis is established
  • If oral medication cannot be taken during or after surgical procedures, consider a parenteral anticoagulant

Note that the half-life of XARELTO® is 5 to 9 hours in healthy subjects aged 20 to 45 years and 11 to 13 hours in the elderly.

Other administration options

ORAL ADMINISTRATION OF CRUSHED XARELTO® TABLETS

Crush XARELTO® tablet

Mix with applesauce

Administer orally immediately

Follow 15-mg and 20-mg doses immediately with food (Not required for 2.5-mg and 10-mg doses)

ADMINISTRATION OF XARELTO® VIA NG OR GASTRIC FEEDING TUBE

Confirm tube placement

Suspend crushed XARELTO® tablet in 50 mL of water

Administer immediately

Avoid administration distal to stomach

Follow 15-mg and 20-mg doses immediately by enteral feeding (Not required for 2.5-mg and 10-mg doses)

aPCC = activated prothrombin complex concentrate; DOAC = direct oral anticoagulant; INR = international normalized ratio; NG = nasogastric; PCC = prothrombin complex concentrate; rFVIIa = recombinant factor VII.