Xarelto

Xarelto

rivaroxaban

Manufacturer:

Bayer Indonesia
Full Prescribing Info
Contents
Rivaroxaban.
Description
10 mg: Each film-coated tablet contains 10 mg rivaroxaban.
15 mg: 1 film-coated tablet contains 15 mg rivaroxaban.
20 mg: 1 film-coated tablet contains 20 mg rivaroxaban.
Excipients/Inactive Ingredients: 15 and 20 mg: Microcrystalline cellulose; Croscarmellose sodium; Lactose monohydrate; Hypromellose; Sodium laurilsulfate; Magnesium stearate; Macrogol 3350; Hypromellose; Titanium dioxide (E171); Iron oxide red (E172).
Action
Pharmacotherapeutic group: 10 mg: Direct factor Xa inhibitors. 15 and 20 mg: Other antithrombotic agents. ATC Code: 10 mg: B01AF01. 15 and 20 mg: B01AX06.
Pharmacology: Pharmacodynamics: Mechanism of action: Rivaroxaban is a highly selective direct factor Xa inhibitor with oral bioavailability. Inhibition of Factor Xa interrupts the intrinsic and extrinsic pathway of the blood coagulation cascade, inhibiting both thrombin formation and development of thrombi. Rivaroxaban does not inhibit thrombin (activated Factor II) and no effects on platelets have been demonstrated.
Pharmacodynamic effects: Dose-dependent inhibition of Factor Xa activity was observed in humans. Prothrombin Time (PT) is influenced by rivaroxaban in a dose dependent way with a close correlation to plasma concentrations (r value equals 0.98) if Neoplastin is used for the assay. Other reagents would provide different results.
The readout for PT is to be done in seconds, because the INR (International Normalized Ratio) is only calibrated and validated for coumarins and cannot be used for any other anticoagulant.
The activated partial thromboplastin time (aPTT) and HepTest are also prolonged dose-dependently; however, they are not recommended to asses the pharmacodynamic effect of rivaroxaban.
10 mg: In patients undergoing major orthopedic surgery, the 5/95 percentiles for PT (Neoplastin) 2-4 hours after tablet intake (i.e. at the time of maximum effect) ranged from 13 to 25 s (baseline values before surgery 12 to 15s).
Anti Factor Xa activity is also influenced by rivaroxaban; however, no standard for calibration is available.
There is no need for monitoring of coagulation parameters during treatment with Xarelto in clinical routine.
15 and 20 mg: In patients receiving rivaroxaban for treatment of DVT and haemodynamically stable PE, the 5/95 percentiles for PT (Neoplastin) 2-4 hours after tablet intake (i.e. at the time of maximum effect) for 15 mg rivaroxaban twice daily ranged from 17 to 32 s and for 20 mg rivaroxaban once daily from 15 to 30 s. At trough (8-16 h after tablet intake) the 5/95 percentiles for 15 mg twice daily ranged from 14 to 24 s and for 20 mg once daily (18-30 h after tablet intake) from 13 to 20 s.
In patients with non-valvular atrial fibrillation receiving rivaroxaban for the prevention of stroke and systemic embolism, the 5/95 percentiles for PT (Neoplastin) 1-4 hours after tablet intake (i.e. at the time of maximum effect) in patients treated with 20 mg once daily ranged from 14 to 40 s and in patients with moderate renal impairment treated with 15 mg once daily from 10 to 50 s. At trough (16-36 h after tablet intake) the 5/95 percentiles in patients treated with 20 mg once daily ranged from 12 to 26 s and in patients with moderate renal impairment treated with 15 mg once daily from 12 to 26 s.
There is no need for monitoring of coagulation parameters during treatment with rivaroxaban in clinical routine. However, if clinically indicated rivaroxaban levels can be measured by calibrated quantitative anti-Factor Xa tests (see Pharmacokinetics as follows).
Clinical efficacy and safety: 10 mg: The rivaroxaban clinical programme was designed to demonstrate the efficacy of Xarelto for the prevention of VTE, i.e. proximal and distal deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery of the lower limbs. Over 9,500 patients (7,050 in total hip replacement surgery and 2,531 in total knee replacement surgery) were studied in controlled randomized double-blind phase III clinical studies, the RECORD-programme.
Xarelto 10 mg once daily (od) started no sooner than 6 hours post-operatively was compared with enoxaparin 40 mg once daily started 12 hours pre-operatively.
In all three phase III studies (see Table 1), rivaroxaban significantly reduced the rate of total VTE (any venographically detected or symptomatic DVT, non fatal PE and death) and major VTE (proximal DVT, non fatal PE and VTE-related death), the pre-specified primary and major secondary efficacy endpoints. Furthermore, in all three studies the rate of symptomatic VTE (symptomatic DVT, non fatal PE and VTE-related death) was lower in Xarelto treated patients compared to patients treated with enoxaparin.
The main safety endpoint, major bleeding, showed comparable rates for patients treated with Xarelto 10 mg compared to enoxaparin 40 mg. (See Table 1.)


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The analysis of the pooled results of the phase III trials corroborated the data obtained in the individual studies regarding reduction of total VTE, major VTE and symptomatic VTE with Xarelto 10 mg once daily compared to enoxaparin 40 mg once daily.
In addition to the phase III RECORD program, a post-authorization, non-interventional, open-label cohort study (XAMOS) has been conducted in 17,413 patients undergoing major orthopaedic surgery of the hip or knee, to compare rivaroxaban with other pharmacological thromboprophylaxis (standard-of-care) under real-life setting. Symptomatic VTE occurred in 57 (0.6%) patients in the rivaroxaban group (n=8,778) and 88 (1.0%) of patients in the standard-of-care group (n=8,635; HR 0.63; 95% CI 0.43-0.91); safety population). Major bleeding occurred in 35 (0.4%) and 29 (0.3%) of patients in the rivaroxaban and standard-of-care groups (HR 1.10; 95% CI 0.67-1.80). Thus, the results were consistent with the results of the pivotal randomised studies.
15 and 20 mg: Xarelto is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: with previous history of stroke or TIA; with CHADS2 Score ≥2.
The Xarelto clinical program was designed to demonstrate the efficacy of Xarelto in reducing the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation.
In the pivotal double-blind ROCKET AF study, 14,264 patients were assigned either to Xarelto 20 mg once daily (15 mg once daily in patients with creatinine clearance 30-49 ml/min) or to warfarin titrated to a target INR of 2.5 (therapeutic range 2.0 to 3.0). The median time on treatment was 19 months and overall treatment duration was up to 41 months.
34.9% of patients were treated with acetylsalicylic acid and 11.4% were treated with class III antiarrhythmic including amiodarone.
Xarelto was non-inferior to warfarin for the primary composite endpoint of stroke and non-CNS systemic embolism. In the per-protocol population on treatment, stroke or systemic embolism occurred in 188 patients on rivaroxaban (1.71% per year) and 241 on warfarin (2.16% per year) (HR 0.79; 95% CI, 0.66-0.96; P<0.001 for non-inferiority). Among all randomised patients analysed according to ITT, primary events occurred in 269 on rivaroxaban (2.12% per year) and 306 on warfarin (2.42% per year) (HR 0.88; 95% CI, 0.74-1.03; P<0.001 for non-inferiority; P=0.117 for superiority). Results for secondary endpoints as tested in hierarchical order in the ITT analysis are displayed in Table 2.
Among patients in the warfarin group, INR values were within the therapeutic range (2.0 to 3.0) a mean of 55% of the time (median, 58%; interquartile range, 43 to 71). The effect of rivaroxaban did not differ across the level of centre TTR (Time in Target INR Range of 2.0-3.0) in the equally sized quartiles (P=0.74 for interaction). Within the highest quartile according to centre, the hazard ratio with rivaroxaban versus warfarin was 0.74 (95% CI, 0.49-1.12).
The incidence rates for the principal safety outcome (major and non-major clinically relevant bleeding events) were similar for both treatment groups (see Table 3).


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Patients undergoing cardioversion: A prospective, randomized, open-label, multicenter, exploratory study with blinded endpoint evaluation (X-VERT) was conducted in 1504 patients (oral anticoagulant naive and pre-treated) with non-valvular atrial fibrillation scheduled for cardioversion to compare rivaroxaban with dose-adjusted VKA (randomized 2:1), for the prevention of cardiovascular events. TEE-guided (1-5 days of pretreatment) or conventional cardioversion (at least three weeks of pre-treatment) strategies were employed. The primary efficacy outcome (all stroke, transient ischemic attack, non-CNS systemic embolism, MI and cardiovascular death) occurred in 5 (0.5%) patients in the rivaroxaban group (n=978) and 5 (1.0%) patients in the VKA group (n=492; RR 0.50; 95% CI 0.15-1.73; modified ITT population). The principal safety outcome (major bleeding) occurred in 6 (0.6%) and 4 (0.8%) patients in the rivaroxaban (n=988) and VKA (n=499) groups, respectively (RR 0.76; 95% CI 0.21-2.67; safety population). This exploratory study showed comparable efficacy and safety between rivaroxaban and VKA treatment groups in the setting of cardioversion.
Treatment of DVT in which duration of treatment should be based on the underlying disease and treatment of haemodynamically stable pulmonary embolism (PE) which is must be confirmed by spiral CT imaging: The Xarelto clinical program was designed to demonstrate the efficacy of Xarelto in the initial and continued treatment of DVT in which duration of treatment should be based on the underlying disease and treatment of haemodynamically stable pulmonary embolism (PE) which is must be confirmed by spiral CT imaging.
Over 9,400 patients were studied in three randomised controlled phase III clinical studies (Einstein DVT, Einstein PE and Einstein Extension) and additionally a predefined pooled analysis of the Einstein DVT and Einstein PE studies was conducted. The overall combined treatment duration in all studies was up to 21 months.
In Einstein DVT 3,449 patients with acute DVT were studied for the treatment of DVT and to reduce the risk of recurrent DVT and PE (patients who presented with symptomatic PE were excluded from this study). The treatment duration was for 3, 6 or 12 months depending on the clinical judgement of the investigator.
For the initial 3 week treatment of acute DVT 15 mg rivaroxaban was administered twice daily. This was followed by 20 mg rivaroxaban once daily.
In Einstein PE, 4,832 patients with acute PE were studied for the treatment of PE and to reduce the risk of recurrent DVT and PE. The treatment duration was for 3, 6 or 12 months depending on the clinical judgement of the investigator.
For the initial treatment of acute PE 15 mg rivaroxaban was administered twice daily for three weeks. This was followed by 20 mg rivaroxaban once daily.
In both the Einstein DVT and the Einstein PE study, the comparator treatment regimen consisted of enoxaparin administered for at least 5 days in combination with vitamin K antagonist treatment until the PT/INR was in therapeutic range (≥2.0). Treatment was continued with a vitamin K antagonist dose-adjusted to maintain the PT/INR values within the therapeutic range of 2.0 to 3.0.
In Einstein Extension 1,197 patients with DVT or PE were studied for reducing the risk of recurrent DVT and PE. The treatment duration was for an additional 6 or 12 months in patients who had completed 6 to 12 months of treatment for venous thromboembolism depending on the clinical judgment of the investigator. Xarelto 20 mg once daily was compared with placebo.
All phase III studies used the same pre-defined primary and secondary efficacy outcomes. The primary efficacy outcome was symptomatic recurrent VT E defined as the composite of recurrent DVT or fatal or non-fatal PE. The secondary efficacy outcome was defined as the composite of recurrent DVT, non-fatal PE and all cause mortality.
In the Einstein DVT study (see Table 4) rivaroxaban was demonstrated to be non-inferior to enoxaparin/VKA for the primary efficacy outcome (p<0.0001 (test for non-inferiority); hazard ratio: 0.680 (0.443-1.042), p=0.076 (test for superiority)). The prespecified net clinical benefit (primary efficacy outcome plus major bleeding events) was reported with a hazard ratio of 0.67 ((95% CI: 0.47-0.95), nominal p value p=0.027) in favour of rivaroxaban. INR values were within the therapeutic range a mean of 60.3% of the time for the mean treatment duration of 189 days, and 55.4%, 60.1%, and 62.8% of the time in the 3-, 6-, and 12-month intended treatment duration groups, respectively. In the enoxaparin/VKA group, there was no clear relation between the level of mean centre TTR (Time in Target INR Range of 2.0-3.0) in the equally sized tertiles and the incidence of the recurrent VTE (P=0.932 for interaction). Within the highest tertile according to centre, the hazard ratio with rivaroxaban versus warfarin was 0.69 (95% CI: 0.35-1.35).
The incidence rates for the primary safety outcome (major or clinically relevant non-major bleeding events) as well as the secondary safety outcome (major bleeding events) were similar for both treatment groups. (See Table 4.)


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In the Einstein PE study (see Table 5) rivaroxaban was demonstrated to be non-inferior to enoxaparin/VKA for the primary efficacy outcome (p=0.0026 (test for non-inferiority); hazard ratio: 1.123 (0.749-1.684)). The prespecified net clinical benefit (primary efficacy outcome plus major bleeding events) was reported with a hazard ratio of 0.849 ((95% CI: 0.633-1.139), nominal p value=0.275). INR values were within the therapeutic range a mean of 63% of the time for the mean treatment duration of 215 days, and 57%, 62%, and 65% of the time in the 3-, 6-, and 12-month intended treatment duration groups, respectively. In the enoxaparin/VKA group, there was no clear relation between the level of mean centre TTR (Time in Target INR Range of 2.0-3.0) in the equally sized tertiles and the incidence of the recurrent VTE (p=0.082 for interaction). Within the highest tertile according to centre, the hazard ratio with rivaroxaban versus warfarin was 0.642 (95% CI: 0.277-1.484).
The incidence rates for the primary safety outcome (major or clinically relevant non-major bleeding events) was slightly lower in the rivaroxaban treatment group (10.3% (249/2412)) than in the enoxaparin/VKA treatment group (11.4% (274/2405)). The incidence of the secondary safety outcome (major bleeding events) was lower in the rivaroxaban group (1.1% (26/2412)) than in the enoxaparin/VKA group (2.2% (52/2405)) with a hazard ratio 0.493 (95% CI: 0.308-0.789). (See Table 5.)


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A prespecified pooled analysis of the outcome of the Einstein DVT and PE studies was conducted (see Table 6).


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The prespecified net clinical benefit (primary efficacy outcome plus major bleeding events) of the pooled analysis was reported with a hazard ratio of 0.771 ((95% CI: 0.614-0.967), nominal p value p= 0.0244).
In the Einstein Extension study (see Table 7) rivaroxaban was superior to placebo for the primary and secondary efficacy outcomes. For the primary safety outcome (major bleeding events) there was a non-significant numerically higher incidence rate for patients treated with rivaroxaban 20 mg once daily compared to placebo. The secondary safety outcome (major or clinically relevant non-major bleeding events) showed higher rates for patients treated with rivaroxaban 20 mg once daily compared to placebo. (See Table 7.)


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Paediatric population: The European Medicines Agency has deferred the obligation to submit the results of studies with Xarelto in one or more subsets of the paediatric population in the treatment of thromboembolic events. The European Medicines Agency has waived the obligation to submit the results of studies with Xarelto in all subsets of the paediatric population in the prevention of thromboembolic events. See Dosage & Administration for information on paediatric use.
Pharmacokinetics: Absorption: Rivaroxaban is rapidly absorbed with maximum concentration (Cmax) appearing 2-4 hours after tablet intake. Oral absorption of rivaroxaban is almost complete and oral bioavailability is high (80-100%) for the 10 mg tablet dose, irrespective of fasting/fed conditions. Intake with food does not affect rivaroxaban AUC or Cmax at the 10 mg dose.
Variability in rivaroxaban pharmacokinetics is moderate with inter-individual variability (CV%) ranging from 30% to 40%.
10 mg: Xarelto 10 mg tablets can be taken with or without food. Rivaroxaban pharmacokinetics are approximately linear up to about 15 mg once daily. At higher doses rivaroxaban displays dissolution limited absorption with decreased bioavailability and decreased absorption rate with increased dose. This is more marked in fasting state than in fed state.
15 and 20 mg: Due to a reduced extent of absorption an oral bioavailability of 66% was determined for the 20 mg tablet under fasting conditions. When Xarelto 20 mg tablets are taken together with food increases in mean AUC by 39% were observed when compared to tablet intake under fasting conditions, indicating almost complete absorption and high oral bioavailability. Xarelto 15 mg and 20 mg are to be taken with food (see Dosage & Administration).
Rivaroxaban pharmacokinetics are approximately linear up to about 15 mg once daily in fasting state. Under fed conditions Xarelto 10 mg, 15 mg and 20 mg tablets demonstrated dose-proportionality. At higher doses rivaroxaban displays dissolution limited absorption with decreased bioavailability and decreased absorption rate with increased dose.
Distribution: Plasma protein binding in humans is high at approximately 92% to 95%, with serum albumin being the main binding component. The volume of distribution is moderate with Vss being approximately 50 litres.
Metabolism and Elimination: Of the administered rivaroxaban dose, approximately ⅔ undergoes metabolic degradation, with half then being eliminated renally and the other half eliminated by the faecal route. The final ⅓ of the administered dose undergoes direct renal excretion as unchanged active substance in the urine, mainly via active renal secretion.
Rivaroxaban is metabolized via CYP3A4, CYP2J2 and CYP-independent mechanisms. Oxidative degradation of the morpholinone moiety and hydrolysis of the amide bonds are the major sites of biotransformation. Based on in vitro investigations rivaroxaban is a substrate of the transporter proteins P-gp (P-glycoprotein) and Bcrp (breast cancer resistance protein).
Unchanged rivaroxaban is the most important compound in human plasma, with no major or active circulating metabolites being present. With a systemic clearance of about 10 l/h, rivaroxaban can be classified as a low-clearance drug. After intravenous administration of a 1 mg dose the elimination half-life is about 4.5 hours.
10 mg: After oral administration of a 10 mg dose the elimination becomes absorption rate limited with mean terminal half-lives of 7 to 11 hours.
15 and 20 mg: After oral administration the elimination becomes absorption rate limited. Elimination of rivaroxaban from plasma occurs with terminal half-lives of 5 to 9 hours in young individuals, and with terminal half-lives of 11 to 13 hours in the elderly.
Special populations: 10 mg: Gender: There were no clinically relevant differences in pharmacokinetics and pharmacodynamics between male and female patients.
Elderly population: Elderly patients exhibited higher plasma concentrations than younger patients, with mean AUC values being approximately 1.5 fold higher, mainly due to reduced (apparent) total and renal clearance. No dose adjustment is necessary.
Different weight categories: Extremes in body weight (<50 kg or >120 kg) had only a small influence on rivaroxaban plasma concentrations (less than 25%). No dose adjustment is necessary.
Inter-ethnic differences: No clinically relevant inter-ethnic differences among Caucasian, African-American, Hispanic, Japanese or Chinese patients were observed regarding rivaroxaban pharmacokinetics and pharmacodynamics.
Hepatic impairment: Cirrhotic patients with mild hepatic impairment (classified as Child Pugh A) exhibited only minor changes in rivaroxaban pharmacokinetics (1.2 fold increase in rivaroxaban AUC on average), nearly comparable to their matched healthy control group. In cirrhotic patients with moderate hepatic impairment (classified as Child Pugh B), rivaroxaban mean AUC was significantly increased by 2.3 fold compared to healthy volunteers. Unbound AUC was increased 2.6 fold. These patients also had reduced renal elimination of rivaroxaban, similar to patients with moderate renal impairment. There are no data in patients with severe hepatic impairment.
The inhibition of Factor Xa activity was increased by a factor of 2.6 in patients with moderate hepatic impairment as compared to healthy volunteers; prolongation of PT was similarly increased by a factor of 2.1. Patients with moderate hepatic impairment were more sensitive to rivaroxaban resulting in a steeper PK/PD relationship between concentration and PT.
10 mg: Xarelto is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk. Xarelto may be used with caution in cirrhotic patients with moderate hepatic impairment (Child Pugh B) if it is not associated with coagulopathy. (see Contraindications and Precautions).
15 and 20 mg: Xarelto is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk, including cirrhotic patients with Child Pugh B and C (see Contraindications).
Renal impairment: There was an increase in rivaroxaban exposure correlated to decrease in renal function, as assessed via creatinine clearance measurements. In individuals with mild (creatinine clearance 50-80 ml/min), moderate (creatinine clearance 30-49 ml/min) and severe (creatinine clearance 15-29 ml/min) renal impairment, rivaroxaban plasma concentrations (AUC) were increased 1.4, 1.5 and 1.6 fold respectively. Corresponding increases in pharmacodynamic effects were more pronounced. In individuals with mild, moderate and severe renal impairment the overall inhibition of factor Xa activity was increased by a factor of 1.5, 1.9 and 2.0 respectively as compared to healthy volunteers; prolongation of PT was similarly increased by a factor of 1.3, 2.2 and 2.4 respectively. There are no data in patients with creatinine clearance <15 ml/min.
Due to the high plasma protein binding rivaroxaban is not expected to be dialysable.
Use is not recommended in patients with creatinine clearance <15 ml/min. Xarelto is to be used with caution in patients with creatinine clearance 15-29 ml/min (see Precautions).
Pharmacokinetic data in patients: 15 and 20 mg: In patients receiving rivaroxaban for treatment of acute DVT 20 mg once daily the geometric mean concentration (90% prediction interval) 2-4 h and about 24 h after dose (roughly representing maximum and minimum concentrations during the dose interval) was 215 (22-535) and 32 (6-239) μg/l, respectively.
Pharmacokinetic/pharmacodynamic relationship: The pharmacokinetic/pharmacodynamic (PK/PD) relationship between rivaroxaban plasma concentration and several PD endpoints (Factor Xa inhibition, PT, aPTT, HepTest) has been evaluated after administration of a wide range of doses (5-30 mg twice a day). 10 mg: Rivaroxaban 10 mg od results in a steady state Cmax of about 125μg/l. The relationship between rivaroxaban concentration and Factor Xa activity was best described by an Emax model. For PT, the linear intercept model generally described the data better. Depending on the different PT reagents used, the slope differed considerably. When Neoplastin PT was used, baseline PT was about 13 s and the slope was around 3 to 4 s/(100μg/l). The results of the PK/PD analyses in Phase II were consistent with the data established in healthy subjects. In patients, baseline Factor Xa and PT were influenced by the surgery resulting in a difference in the concentration-PT slope between the day post-surgery and steady state.
15 and 20 mg: The relationship between rivaroxaban concentration and Factor Xa activity was best described by an Emax model. For PT, the linear intercept model generally described the data better. Depending on the different PT reagents used, the slope differed considerably. When Neoplastin PT was used, baseline PT was about 13 s and the slope was around 3 to 4 s/(100 μg/l). The results of the PK/PD analyses in Phase II and III were consistent with the data established in healthy subjects.
Paediatric population: 15 and 20 mg: Safety and efficacy have not been established for children and adolescents up to 18 years.
Toxicology: Preclinical safety data: Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, single dose toxicity, phototoxicity, genotoxicity (15 and 20 mg: Carcinogenic potential and reproductive toxicity). Effects observed in repeat-dose toxicity studies were mainly due to the exaggerated pharmacodynamic activity of rivaroxaban. In rats, increased IgG and IgA plasma levels were seen at clinically relevant exposure levels.
Animal studies have shown reproductive toxicity related to the pharmacological mode of action of rivaroxaban (e.g. haemorrhagic complications). Embryo-foetal toxicity (post-implantation loss, retarded/progressed ossification, multiple light coloured spots) and an increased incidence of common malformations as well as placental changes were observed at clinically relevant plasma concentrations. In the pre- and post-natal study in rats, reduced viability of the off spring was observed at doses that were toxic to the dam.
15 and 20 mg: In rats, no effects on male or female fertility were seen.
Carcinogenicity: 10 mg: Rivaroxaban was tested up to 60 mg/kg/day reaching exposure levels similar to humans (mice) or up to 3.6-fold higher (rats) than in humans.
Rivaroxaban showed no carcinogenic potential in rats and mice.
Indications/Uses
10 mg: Xarelto is indicated for prevention of venous thromboembolism (VTE) in adult patients undergoing elective hip or knee replacement surgery.
15 and 20 mg: Xarelto is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: with previous history of stroke or TIA;
with CHADS2 Score ≥2.
Xarelto is indicated for the treatment of Deep Vein Thrombosis (DVT) in which duration of treatment should be based on the underlying disease.
Xarelto is indicated for the treatment of patients with haemodynamically stable pulmonary embolism (PE) which is must be confirmed by spiral CT imaging.
Dosage/Direction for Use
10 mg: The recommended dose is 10 mg Xarelto taken orally once daily. The initial dose should be taken 6 to 10 hours after surgery, provided that haemostasis has been established.
The duration of treatment depends on the individual risk of the patient for venous thromboembolism which is determined by the type of orthopaedic surgery.
For patients undergoing major hip surgery, a treatment duration of 5 weeks is recommended.
For patients undergoing major knee surgery, a treatment duration of 2 weeks is recommended.
Missed Dose: If a dose is missed the patient should take Xarelto immediately and then continue the following day with once daily intake as before.
Xarelto can be taken with or without food.
Renal impairment: No dose adjustment is necessary in patients with mild renal impairment (creatinine clearance 50-80ml/min) or moderate renal impairment (creatinine clearance 30-49 ml/min) (see Pharmacology: Pharmacokinetics under Actions). Limited clinical data for patients with severe renal impairment (creatinine clearance 15-29 ml/min) indicate that Xarelto plasma concentrations are significantly increased in this patient population, therefore, Xarelto is to be used with caution in these patients. Use is not recommended in patients with creatinine clearance <15 ml/min (see Pharmacology: Pharmacokinetics under Actions and Precautions).
Hepatic impairment: Xarelto is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk (see Pharmacology: Pharmacokinetics under Actions and Contraindications). Xarelto may be used with caution in cirrhotic patients with moderate hepatic impairment (Child Pugh B) if it is not associated with coagulopathy (see Pharmacology: Pharmacokinetics under Actions and Precautions).
No dose adjustment is necessary in patients with other hepatic diseases.
Patients above 65 years: No dose adjustment is required based on age.
Body weight: No dose adjustment is required based on body weight.
Gender: No dose adjustment is required based on gender.
Children and adolescents: Xarelto is not recommended for use in children or adolescents below 18 years of age due to a lack of data on safety and efficacy.
15 and 20 mg: To reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: with previous history of stroke or TIA; with CHADS2 score ≥2.
The recommended dose is 20 mg once daily, which is also the recommended maximum dose.
Therapy with Xarelto should be continued long term provided the benefit of reducing the risk of stroke and systemic embolism outweighs the risk of bleeding (see Precautions).
If a dose is missed the patient should take Xarelto immediately and continue on the following day with the once daily intake as recommended. The dose should not be doubled within the same day to make up for a missed dose.
For the treatment of Deep Vein Thrombosis (DVT) in which duration on treatment should be based on the underlying disease and the treatment of patients with haemodynamicallv stable pulmonary embolism (PE): The recommended dose for the initial treatment of acute DVT or PE is 15 mg twice daily for the first three weeks followed by 20 mg once daily for the continued treatment, as indicated in the table as follows. (See Table 8.)


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The duration of therapy should be individualised after careful assessment of the treatment benefit against the risk for bleeding (see Precautions). Short duration of therapy at least 3 months) should be based on transient risk factors (e.g. recent surgery, trauma, immobilisation) and longer durations should be based on permanent risk factors or idiopathic DVT or PE.
If a dose is missed during the 15 mg twice daily treatment phase (day 1-21), the patient should take Xarelto immediately to ensure intake of 30 mg Xarelto per day. In this case two 15 mg tablets may be taken at once. The patient should continue with the regular 15 mg twice daily intake as recommended on the following day.
If a dose is missed during the once daily treatment phase (day 22 and onwards), the patient should take Xarelto immediately, and continue on the following day with the once daily intake as recommended. The dose should not be doubled within the same day to make up for a missed dose.
Converting from Vitamin K Antagonists (VKA) to Xarelto: For patients treated for reducing the risk of stroke and systemic embolism, VKA treatment should be stopped and Xarelto therapy should be initiated when the INR is ≤3.0.
For patients treated for DVT or PE, VKA treatment should be stopped and Xarelto therapy should be initiated once the INR is ≤2.5.
When converting patients from VKAs to Xarelto, INR values will be falsely elevated after the intake of Xarelto. The INR is not valid to measure the anticoagulant activity of Xarelto, and therefore should not be used (see Interactions).
Converting from Xarelto to Vitamin K antagonists (VKA): There is a potential for inadequate anticoagulation during the transition from Xarelto to VKA. Continuous adequate anticoagulation should be ensured during any transition to an alternate anticoagulant. It should be noted that Xarelto can contribute to an elevated INR.
In patients converting from Xarelto to VKA, VKA should be given concurrently until the INR is ≥2.0. For the first two days of the conversion period, standard initial dosing of VKA should be used followed by VKA dosing guided by INR testing. While patients are on both Xarelto and VKA the INR should not be tested earlier than 24 hours after the previous dose but prior to the next dose of Xarelto. Once Xarelto is discontinued INR testing may be done reliably at least 24 hours after the last dose (see Pharmacology: Pharmacokinetics under Actions and Interactions).
Converting from parenteral anticoagulants to Xarelto: For patients currently receiving a parenteral anticoagulant, Xarelto should be started 0 to 2 hours before the time of the next scheduled administration of the parenteral medicinal product (e.g. LMWH) or at the time of discontinuation of a continuously administered parenteral medicinal product (e.g. intravenous unfractionated heparin).
Converting from Xarelto to parenteral anticoagulants: Give the first dose of parenteral anticoagulant at the time the next Xarelto dose would be taken.
Special populations: Renal impairment: No dose adjustment is necessary in patients with mild renal impairment (creatinine clearance 50-80 ml/min) (see Pharmacology: Pharmacokinetics under Actions).
In patients with moderate (creatinine clearance 30-49 ml/min) or severe (creatinine clearance 15-29 ml/min) renal impairment the following dosage recommendations apply: For reducing the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation, the recommended dose is 15 mg once daily (see Pharmacology: Pharmacokinetics under Actions).
For the treatment of DVT or PE, patients should be treated with 15 mg twice daily for the first 3 weeks. Thereafter, the recommended dose is 15 mg once daily based on PK modelling (see Pharmacology: Pharmacokinetics under Actions and Precautions).
Limited clinical data for patients with severe renal impairment (creatinine clearance 15-29 ml/min) indicate that rivaroxaban plasma concentrations are significantly increased therefore, Xarelto is to be used with caution in these patients. Use is not recommended in patients with creatinine clearance <15 ml/min (see Pharmacology: Pharmacokinetics under Actions and Precautions).
Hepatic impairment: Xarelto is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B and C (see Pharmacology: Pharmacokinetics under Actions and Contraindications).
Elderly population: No dose adjustment (see Pharmacology: Pharmacokinetics under Actions).
Body weight: No dose adjustment (see Pharmacology: Pharmacokinetics under Actions).
Gender: No dose adjustment (see Pharmacology: Pharmacokinetics under Actions).
Paediatric population: The safety and efficacy of Xarelto in children aged 0 to 18 years have not been established. No data are available. Therefore, Xarelto is not recommended for use in children below 18 years of age.
Patients undergoing cardioversion: Xarelto can be initiated or continued in patients who may require cardioversion.
For transesophageal echocardiogram (TEE) guided cardioversion in patients not previously treated with anticoagulants, Xarelto treatment should be started at least 4 hours before cardioversion to ensure adequate anticoagulation (see Pharmacology: Pharmacodynamics under Actions).
Method of administration: For oral use. The tablets are to be taken with food (see Pharmacology: Pharmacokinetics under Actions).
Overdosage
Rare cases of overdose up to 600 mg have been reported without bleeding complications or other adverse reactions. Due to limited absorption a ceiling effect with no further increase in average plasma exposure is expected at supratherapeutic doses of 50 mg or above.
A specific antidote antagonizing the pharmacodynamic effect of rivaroxaban is not available. The use of activated charcoal to reduce absorption in case of Xarelto overdose may be considered. Due to the high plasma protein binding rivaroxaban is not expected to be dialyzable.
Management of Bleeding: Should a bleeding complication arise in a patient receiving rivaroxaban, the next rivaroxaban administration should be delayed or treatment should be discontinued as appropriate. Rivaroxaban has a half-life of approximately 5 to 13 hours (see Pharmacology: Pharmacokinetics under Actions). Management should be individualized according to the severity and location of the hemorrhage. Appropriate symptomatic treatment could be used as needed, such as mechanical compression (e.g. for severe epistaxis), surgical hemostasis with bleeding control procedures, fluid replacement and hemodynamic support, blood products (packed red cells or fresh frozen plasma, depending on associated anemia or coagulopathy) or platelets.
If bleeding cannot be controlled by the previously mentioned measures, administration of a specific procoagulant reversal agent should be considered, such as prothrombin complex concentrate (PCC), activated prothrombin complex concentrate (APCC), or recombinant factor VIIa (r-FVIIa). However, there is currently very limited clinical experience with the use of these products in individuals receiving Xarelto. The recommendation is also based on limited non-clinical data. Re-dosing of recombinant factor VIIa shall be considered and titrated depending on improvement of bleeding.
Protamine sulfate and vitamin K are not expected to affect the anticoagulant activity of rivaroxaban.
There is limited experience with tranexamic acid and no experience with aminocaproic acid and aprotinin in individuals receiving rivaroxaban. There is neither scientific rationale for benefit nor experience with the use of systemic haemostatic desmopressin in individuals receiving rivaroxaban. Due to the high plasma protein binding rivaroxaban is not expected to be dialysable.
Contraindications
Hypersensitivity to the active substance or to any of the excipients.
Clinically significant active bleeding.
Hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B and C (see Pharmacology: Pharmacokinetics under Actions).
Pregnancy and breast feeding (see Use in Pregnancy & Lactation).
15 and 20 mg: Lesion or condition at significant risk of major bleeding such as current or recent gastrointestinal ulceration, presence of malignant neoplasms at high risk of bleeding, recent brain or spinal injury, recent brain, spinal or ophthalmic surgery, recent intracranial haemorrhage, known or suspected oesophageal varices, arteriovenous malformations, vascular aneurysms or major intraspinal or intracerebral vascular abnormalities.
Concomitant treatment with any other anticoagulant agent e.g. unfractionated heparin (UFH), low molecular weight heparins (enoxaparin, dalteparin, etc.), heparin derivatives (fondaparinux, etc.), oral anticoagulants (warfarin, apixaban, dabigatran, etc.) except under the circumstances of switching therapy to or from rivaroxaban (see Dosage & Administration) or when UFH is given at doses necessary to maintain a patent central venous or arterial catheter.
Warnings
15 and 20 mg: A. Premature Discontinuation of Xarelto Increases the Risk of Thrombotic Events: Premature discontinuation of any oral anticoagulant, including XARELTO, increases the risk of thrombotic events. If anticoagulation with XARELTO is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant (see Pharmacology: Pharmacodynamics: Clinical efficacy and safety under Actions, Dosage & Administration and Precautions).
B. Spinal/Epidural Hematoma: Epidural or spinal hematomas have occurred in patients treated with XARELTO who are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: use of indwelling epidural catheters;
concomitant use of other drugs that affect hemostasis, such as non-steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants;
a history of traumatic or repeated epidural or spinal punctures;
a history of spinal deformity or spinal surgery;
optimal timing between the administration of XARELTO and neuraxial procedures is not known (see Precautions and Adverse Reactions).
Monitor patients frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary (see Precautions).
Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis (see Precautions).
Special Precautions
Hemorrhagic risk: Several sub-groups of patients, as detailed as follows, are at increased risk of bleeding. These patients are to be carefully monitored for signs of bleeding complications ann anaemia after initiation of treatment (see Adverse Reactions). This may be done by regular physical examination of the patients, close observation of the surgical wound drainage and periodic measurements of haemoglobin. Any unexplained fall in haemoglobin or blood pressure should lead to a search for a bleeding site.
15 and 20 mg: As with other anticoagulants, patients taking Xarelto are to be carefully observed for signs of bleeding. It is recommended to be used with caution in conditions with increased risk of haemorrhage. Xarelto administration should be discontinued if severe haemorrhage occurs.
In the clinical studies mucosal bleedings (i.e. epistaxis, gingival, gastrointestinal, genito urinary) and anaemia were seen more frequently during long term rivaroxaban treatment compared with VKA treatment. Thus, in addition to adequate clinical surveillance, laboratory testing of haemoglobin/haematocrit could be of value to detect occult bleeding, as judged to be appropriate.
Although treatment with rivaroxaban does not require routine monitoring of exposure, rivaroxaban levels measured with a calibrated quantitative anti-Factor Xa assay may be useful in exceptional situations where knowledge of rivaroxaban exposure may help to inform clinical decisions, e.g., overdose and emergency surgery (see Pharmacology: Pharmacodynamics and Pharmacokinetics under Actions).
Renal impairment: In patients with severe renal impairment (creatinine clearance <30 mL/min) Xarelto plasma levels may be significantly increased which may lead to an increased bleeding risk. Use is not recommended in patients with creatinine clearance <15 ml/min. Xarelto is to be used with caution in patients with creatinine clearance 15-29 mL/min. (see Pharmacology: Pharmacokinetics under Actions and Dosage & Administration).
10 mg: The Azole anti-mycotic fluconazole, a moderate Cyp3A4 inhibitor, has however less effect on rivaroxaban exposure and can be co-administered (see Interactions). Xarelto is to be used with caution in patients with moderate renal impairment (creatinine clearance <50-30 mL/min) concomitantly receiving other medicinal products which increase Xarelto plasma concentrations (see Interactions).
15 and 20 mg: Xarelto should be used with caution in patients with renal impairment concomitantly receiving other medicinal products that are potent inhibitors of CYP3A4 (e.g. clarithromycin, telithromycin) as PK modelling shows increased rivaroxaban concentrations in these patients.
Interaction with other medicinal products: The use of Xarelto is not recommended in patients receiving concomitant systemic treatment with azole-antimycotics (such as ketoconazole, itraconazole, voriconazole and posaconazole) or HIV protease inhibitors (e.g. ritonavir). These active substances are strong inhibitors of both CYP3A4 and P-gp and therefore may increase Xarelto plasma concentrations to a clinically relevant degree which may lead to an increased bleeding risk (see Interactions).
Care is to be taken if patients are treated concomitantly with medicinal products affecting haemostasis such as non-steroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid, platelet aggregation inhibitors or other antithrombotic agents (see Interactions).
10 mg: Fluconazole is expected to have less effect on Xarelto exposure and can be co-administered with caution.
Other haemorrhagic risk factors: Xarelto, like other antithrombotic agents, is to be used with caution in patients with an increased bleeding risk such as: Congenital or acquired bleeding disorders.
Uncontrolled severe arterial hypertension.
Active ulcerative gastrointestinal disease.
Vascular retinopathy.
Bronchiectasis or history of pulmonary bleeding.
10 mg: Recent gastrointestinal ulcerations.
Recent intracranial or intracerebral haemorrhage.
Intra spinal or intracerebral vascular abnormalities.
Recent brain, spinal or ophthalmological surgery.
For patients at risk of ulcerative gastrointestinal disease an appropriate prophylactic treatment may be considered.
15 and 20 mg: There is no need for monitoring of coagulation parameters during treatment with rivaroxaban in clinical routine. However, if clinically indicated rivaroxaban levels can be measured by calibrated quantitative anti-Factor Xa tests (see Pharmacology: Pharmacodynamics and Pharmacokinetics under Actions).
Spinal/epidural anaesthesia or puncture: When neuraxial anaesthesia (spinal/epidural anaesthesia) or spinal/epidural puncture is employed, patients treated with antithrombotic agents for prevention of thromboembolic complications are at risk of developing an epidural or spinal haematoma which can result in long term or permanent paralysis.
The risk of these events may be increased by the post-operative use of in dwelling epidural catheters or the concomitant use of medicinal products affecting haemostasis. The risk may also be increased by traumatic or repeated epidural or spinal puncture. Patients are to be frequently monitored for signs and symptoms of neurological impairment (e.g. numbness or weakness of the legs, bowel or bladder dysfunction). If neurological compromise is noted, urgent diagnosis and treatment is necessary. Prior to neuraxial intervention the physician should consider the potential benefit versus the risk in anticoagulated patients or in patients to be anticoagulated for thromboprophylaxis.
There is no clinical experience with the use of 15 mg and 20 mg rivaroxaban in these situations.
To reduce the potential risk of bleeding associated with the concurrent use of rivaroxaban and neuraxial anaesthesia or spinal puncture, consider the pharmacokinetic profile of rivaroxaban. Placement or removal of an epidural catheter or lumbar puncture is best performed when the anticoagulant effect of rivaroxaban is estimated to be low (see Pharmacology: Pharmacokinetics under Actions). However, the exact timing to reach a sufficiently low anticoagulant effect in each patient is not known.
An epidural catheter is not to be removed earlier than 18 hours after the last administration of Xarelto. The next dose is to be administered not earlier than 6 hours after the removal of the catheter.
If traumatic puncture occurs the administration of Xarelto is to be delayed for 24 hours.
15 and 20 mg: For the removal of an epidural catheter and based on the general PK characteristics at least 2x half-life, i.e. at least 18 hours in young patients and 26 hours in elderly patients should elapse after the last administration of rivaroxaban (see Pharmacology: Pharmacokinetics under Actions). Following removal of the catheter, at least 6 hours should elapse before the next rivaroxaban dose is administered.
If traumatic puncture occurs the administration of rivaroxaban is to be delayed for 24 hours.
Dosing recommendations before and after invasive procedures and surgical intervention other than elective hip or knee replacement surgery: If an invasive procedure or surgical intervention is required, Xarelto 10 mg should be stopped at least 24 hours before the intervention, if possible and bases on the clinical judgement of the physician.
If the procedure cannot be delayed the increased risk of bleeding should be assessed against the urgency of the intervention.
Xarelto should be restarted as soon as possible after the invasive procedure or surgical intervention provided the clinical situation allows and adequate haemostasis has been established as determined by the treating physician (see Pharmacology: Pharmacokinetics under Actions).
Information about excipients: Xarelto contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
10 mg: Hepatic impairment: In cirrhotic patients with moderate hepatic impairment (classified as Child Pugh B), Xarelto plasma levels may be significantly increased which may lead to an increased bleeding risk. Xarelto is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk. Xarelto may be used with caution in cirrhotic patients with moderate hepatic impairment (Child Pugh B) if it is not associated with coagulopathy. (See Pharmacology: Pharmacokinetics under Actions, Dosage & Administration and Contraindications).
Hip fracture surgery: Xarelto has not been studied in interventional clinical trials in patients undergoing hip fracture surgery to evaluate efficacy and safety.
Interaction with CYP3A4 inducers: The concomitant use of Xarelto with strong CYP3A4 inducers (e.g. rifampicin, phenytoin, carbamazepine, Phenobarbital or St. John's Wort) may lead to reduced Xarelto plasma concentrations. Strong CYP3A4 inducers should be co-administered with caution (see Interactions).
15 and 20 mg: Clinical surveillance in line with anticoagulation practice is recommended throughout the treatment period.
Increased Risk of Thrombotic Events after Premature Discontinuation: Premature discontinuation of any oral anticoagulant, including Xarelto, in the absence of adequate alternative anticoagulation increases the risk of thrombotic events. If Xarelto is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant (see Pharmacology: Pharmacodynamics: Clinical efficacy and safety under Actions and Dosage & Administration).
Patients with prosthetic valves: Safety and efficacy of Xarelto have not been studied in patients with prosthetic heart valves; therefore, there are no data to support that Xarelto 20 mg (15 mg in patients with moderate or severe renal impairment) provides adequate anticoagulation in this patient population. Treatment with Xarelto is not recommended for these patients.
Haemodynamically unstable PE patients or patients who require thrombolysis or pulmonary embolectomy: Xarelto is not recommended as an alternative to unfractionated heparin in patients with pulmonary embolism who are haemodynamically unstable or may receive thrombolysis or pulmonary embolectomy since the safety and efficacy of Xarelto have not been established in these clinical situations.
Effecct on ability to drive and use machines: 10 mg: No studies of the effects on the ability to drive and use machines have been performed.
Syncope and dizziness have been reported in the post-operative setting and may affect the ability to drive and use machines, these adverse reactions have been reported to be uncommon (see Adverse Reactions).
Patients experiencing these adverse reactions should not drive or use machines.
15 and 20 mg: Xarelto has minor influence on the ability to drive and use machines. Adverse reactions like syncope and dizziness have been reported to be common (see Adverse Reactions).
Patients experiencing these adverse reactions should not drive or use machines.
Use In Pregnancy & Lactation
Pregnancy: Safety and efficacy of Xarelto have not been established in pregnant women. Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions). Due to the potential reproductive toxicity, the intrinsic risk of bleeding and the evidence that rivaroxaban passes the placenta, Xarelto is contraindicated during pregnancy (see Contraindications).
Women of child-bearing potential should avoid becoming pregnant during treatment with rivaroxaban.
Breast feeding: Safety and efficacy of Xarelto have not been established in breast feeding women. Data from animals indicate that rivaroxaban is secreted into milk. Therefore Xarelto is contraindicated during breast feeding (see Contraindications). A decision must be made whether to discontinue breast feeding or to discontinue/abstain from therapy.
Fertility: 15 and 20 mg: No specific studies with rivaroxaban in humans have been conducted to evaluate effects on fertility. In a study on male and female fertility in rats no effects were seen (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Adverse Reactions
10 mg: The safety of Xarelto 10 mg has been evaluated in four phase III studies including 6097 patients exposed to Xarelto undergoing major orthopaedic surgery of the lower limbs (total hip replacement or total knee replacement) treated for to 39 days.
In total, about 14% of the treated patients experienced adverse reactions. Bleedings or anaemia occurred in approximately 3.3% and 1% of patients, respectively. Other common adverse reactions were nausea, increased GGT and an increase in transaminases. The adverse reactions should be interpreted within the surgical setting.
Due to the pharmacological mode of action, the use of Xarelto may be associated with an increased risk of occult or overt bleeding from any tissue or organ which may result in posthaemorrhagic anaemia.
The signs, symptoms, and severity (including possibly fatal outcome) will vary according to the location and degree or extent of the bleeding and/or anemia. The risk of bleedings may be increased in certain patient groups e.g. those patients with uncontrolled severe arterial hypertension and/or on concomitant treatment with other medicinal products affecting haemostasis (see Haemorrhagic risk under Precautions).
Haemorrhagic complications may present as weakness, paleness, dizziness, headache or unexplained swelling, dyspnea, and unexplained shock. In some cases as a consequence of anemia, symptoms of cardiac ischemia like chest pain or angina pectoris may occur. Therefore, the possibility of haemorrhage is to be considered in evaluating the condition in any anticoagulated patient.
The frequencies of ADRs reported with Xarelto are summarised in the table as follows. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
Frequencies are defined as common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100) and rare (≥1/10,000 to <1/1,000). The ADRs identified only during postmarketing surveillance, and for which a frequency could not be estimated, are listed under "not known". (See Table 9.)


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In other clinical studies vascular pseudoaneurysm formation following percutaneous intervention has been reported. Moreover, in other clinical studies and postmarketing surveillance, known complications secondary to bleeding, such as compartment syndrome, have been reported. Acute renal failure/renal failure secondary to a bleeding event sufficient to cause hypoperfusion have also been reported.
Post-marketing observations: The following adverse reactions have been reported post-marketing in temporal association with the use of Xarelto. The frequency of these adverse reactions reported from post-marketing experience cannot be estimated.
Immune system disorders: Angioedema and allergic oedema (In the pooled phase III trials, these events were uncommon (≥1/1,000 to <1/100).
Hepatobiliary disorders: Cholestasis, Hepatitis (incl. hepatocellular injury) (In the pooled phase III trials, these events were rare (≥1/10,000 to <1/1,000)).
Blood and lymphatic system disorders: Thrombocytopenia (In the pooled phase III trials, these events were uncommon (≥1/1,000 to <1/100)).
15 and 20 mg: Summary of the safety profile: The safety of rivaroxaban has been evaluated in eight phase Ill studies including 18,403 patients exposed to rivaroxaban (see Table 10).


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In total about 73% of patients exposed to at least one dose of rivaroxaban were reported with treatment emergent adverse events. About 24% of the patients experienced adverse events considered related to treatment as assessed by investigators. In patients treated with 10 mg Xarelto undergoing hip or knee replacement surgery, bleeding events occurred in approximately 6.8% of patients and anaemia occurred in approximately 5.9% of patients. In patients treated with either 15 mg twice daily Xarelto followed by 20 mg once daily for treatment of DVT or PE bleeding events occurred in approximately 27.8% of patients and anaemia occurred in approximately 2.2% of patients. In patients treated for reducing the risk of stroke and systemic embolism, bleeding of any type or severity was reported with an event rate of 28 per 100 patient years, and anaemia with an event rate of 2.5 per 100 patient years.
Tabulated list of adverse reactions: The frequencies of adverse reactions reported with Xarelto are summarised in Table 11 as follows by system organ class (in MedDRA) and by frequency.
Frequencies are defined as: common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); Not known: cannot be estimated from the available data. (See Table 11.)


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Description of selected adverse reactions: Due to the pharmacological mode of action, the use of Xarelto may be associated with an increased risk of occult bleeding from any tissue or organ which may result in post haemorrhagic anaemia. The signs, symptoms, and severity (including fatal outcome) will vary according to the location and degree or extent of the bleeding and/or anaemia (see Management of bleeding under Overdosage). In the clinical studies mucosal bleedings (i.e. epistaxis, gingival, gastrointestinal, genito urinary) and anemia were seen more frequently during long term rivaroxaban treatment compared with VKA treatment. Thus, in addition to adequate clinical surveillance, laboratory testing of haemoglobin/haematocrit could be of value to detect occult bleeding, as judged to be appropriate. The risk of bleedings may be increased in certain patient groups e.g. those patients with uncontrolled severe arterial hypertension and/or on concomitant treatment affecting haemostasis (see Haemorrhagic risk under Precautions). Menstrual bleeding may be intensified and/or prolonged. Haemorrhagic complications may present as weakness, paleness, dizziness, headache or unexplained swelling, dyspnoea, and unexplained shock. In some cases as a consequence of anaemia, symptoms of cardiac ischaemia like chest pain or angina pectoris have been observed.
Known complications secondary to severe bleeding such as compartment syndrome and renal failure due to hypoperfusion have been reported for Xarelto. Therefore, the possibility of haemorrhage is to be considered in evaluating the condition in any anticoagulated patient.
Post-marketing observations: The following adverse reactions have been reported post-marketing in temporal association with the use of Xarelto. The frequency of these adverse reactions reported from post-marketing experience cannot be estimated.
Immune system disorders: Angioedema and allergic oedema (In the pooled phase III trials, these events were uncommon (≥1/1,000 to <1/100)).
Hepatobiliary disorders: Cholestasis, Hepatitis (incl. hepatocellular injury) (In the pooled phase III trials, these events were rare (≥1/10,000 to <1/1,000)).
Blood and lymphatic system disorders: Thrombocytopenia (In the pooled phase III trials, these events were uncommon (≥1/1,000 to < 1/100)).
Drug Interactions
CYP3A4 and P-gp inhibitors: Co-administration of rivaroxaban with ketoconazole (400 mg once a day) or ritonavir (600 mg twice a day) led to a 2.6 fold/2.5 fold increase in mean rivaroxaban AUC and a 1.7 fold/1.6 fold increase in mean rivaroxaban Cmax, with significant increases in pharmacodynamic effects which may lead to an increased bleeding risk. Therefore, the use of Xarelto is not recommended in patients receiving concomitant systemic treatment with azole-antimycotics such as ketoconazole, itraconazole, voriconazole and posaconazole or HIV protease inhibitors. These active substances are strong inhibitors of both CYP3A4 and P-gp (see Precautions).
Active substances strongly inhibiting only one of the rivaroxaban elimination pathways, either CYP3A4 or P-gp, are expected to increase rivaroxaban plasma concentrations to a lesser extent. Clarithromycin (500 mg twice a day), for instance, considered as a strong CYP3A4 inhibitor and moderate P-gp inhibitor, led to a 1.5 fold increase in mean rivaroxaban AUC and a 1.4 fold increase in Cmax. This increase is not considered clinically relevant.
Erythromycin (500 mg three times a day), which inhibits CYP3A4 and P-gp moderately, led to a 1.3 fold increase in mean rivaroxaban AUC and Cmax. This increase is not considered clinically relevant.
Fluconazole (400 mg once daily), considered as a moderate CYP3A4 inhibitor, led to a 1.4 fold increase in mean rivaroxaban AUC and a 1.3 fold increase in mean Cmax. This increase is not considered clinically relevant.
10 mg: Fluconazole is expected to have less effect on Xarelto exposure and can be co-administered with caution.
15 and 20 mg: Given the limited clinical data available with dronedarone, co-administration with rivaroxaban should be avoided.
Anticoagulants: After combined administration of enoxaparin (40 mg single dose) with rivaroxaban (10 mg single dose) an additive effect on anti-Factor Xa activity was observed without any additional effects on clotting tests (PT, aPTT). Enoxaparin did not affect the pharmacokinetics of rivaroxaban.
Due to the increased bleeding risk care is to be taken if patients are treated concomitantly with any other anticoagulants (see Precautions).
NSAIDs/platelet aggregation inhibitors: No clinically relevant prolongation of bleeding time was observed after concomitant administration of rivaroxaban (15 mg) and 500 mg naproxen. Nevertheless, there may be individuals with a more pronounced pharmacodynamic response.
No clinically significant pharmacokinetic or pharmacodynamic interactions were observed when rivaroxaban was co-administered with 500 mg acetylsalicylic acid.
Clopidogrel (300 mg loading dose followed by 75 mg maintenance dose) did not show a pharmacokinetic interaction with rivaroxaban (15 mg) but a relevant increase in bleeding time was observed in a subset of patients which was not correlated to platelet aggregation, P-selectin or GPIIb/IIIa receptor levels.
Care is to be taken if patients are treated concomitantly with NSAIDs (including acetylsalicylic acid) and platelet aggregation inhibitors because these medicinal products typically increase the bleeding risk (see Precautions).
CYP3A4 inducers: Co-administration of rivaroxaban with the strong CYP3A4 inducer rifampicin led to an approximate 50% decrease in mean rivaroxaban AUC, with parallel decreases in its pharmacodynamic effects. The concomitant use of rivaroxaban with other strong CYP3A4 inducers (e.g. phenytoin, carbamazepine, phenobarbital or St. John's Wort) may also lead to reduced rivaroxaban plasma concentrations. Strong CYP3A4 inducers should be co-administered with caution.
Other concomitant therapies: Rivaroxaban neither inhibits nor induces any major CYP isoforms like CYP3A4.
No clinically significant pharmacokinetic or pharmacodynamic interactions were observed when was co-administered with midazolam (substrate of CYP3A4), digoxin (substrate of P-gp) or atorvastatin (substrate of CYP3A4 and P-gp).
Co-administration of the proton pump inhibitor omeprazole did not affect rivaroxaban bioavailability and pharmacokinetics.
10 mg: No clinically relevant interaction with food was observed (see Dosage & Administration).
Laboratory parameters: Clotting parameters (e.g. PT, aPTT, HepTest) are affected as expected by the mode of action of rivaroxaban (see Pharmacology: Pharmacodynamics under Actions).
Warfarin: 15 and 20 mg: Converting patients from the vitamin K antagonist warfarin (INR 2.0 to 3.0) to rivaroxaban (20 mg) or from rivaroxaban (20 mg) to warfarin (INR 2.0 to 3.0) increased prothrombin time/lNR (Neoplastin) more than additively (individual INR values up to 12 may be observed), whereas effects on aPTT, inhibition of factor Xa activity and endogenous thrombin potential were additive.
If it is desired to test the pharmacodynamic effects of rivaroxaban during the conversion period, anti-factor Xa activity, PiCT, and Heptest can be used as these tests were not affected by warfarin. On the fourth day after the last dose of warfarin, all tests (including PT, aPTT, inhibition of factor Xa activity and ETP) reflected only the effect of rivaroxaban.
If it is desired to test the pharmacodynamic effect of warfarin during the conversion period, INR measurement can be used at the Ctrough of rivaroxaban (24 hours after the previous intake of rivaroxaban) as this test is minimally affected by rivaroxaban at this time point.
No pharmacokinetic interaction was observed between warfarin and rivaroxaban.
Caution For Usage
Incompatibilities: 15 and 20 mg: Not applicable.
Storage
10 mg: Store below 30°C.
15 and 20 mg: Do not store above 30°C.
Shelf-Life: 3 years.
ATC Classification
B01AF01 - rivaroxaban ; Belongs to the class of direct factor Xa inhibitors. Used in the treatment of thrombosis.
Presentation/Packing
FC tab 10 mg x 10's. 15 mg (red, round, biconvex, marked with the BAYER-cross on one side and "15" and a triangle on the other side) x 2 x 14's. 20 mg (brown-red, round, biconvex, marked with the BAYER-cross on one side and "20" and a triangle on the other side) x 2 x 14's.
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