Bleeding and overanticoagulation with rivaroxaban

The following information applies to bleeding and overanticoagulation in patients taking rivaroxaban therapeutically; for information on management of rivaroxaban poisoning, see Apixaban and rivaroxaban poisonings in the Toxicology and Toxinology guidelines.

For factors that increase the risk of bleeding with rivaroxaban, see Patient-associated factors that increase bleeding risk with anticoagulant therapy; clinical trials of rivaroxaban excluded patients with these risk factors.

If bleeding occurs in a patient taking rivaroxaban therapeutically, stop rivaroxaban and provide supportive treatment.

Rivaroxaban is not dialysable as it is extensively bound to plasma protein. Rivaroxaban is rapidly absorbed, so although activated charcoal can be considered for rivaroxaban poisonings, it is not recommended for management of acute bleedingFrontera, 2016. At the time of writing, andexanet alfa (a recombinant inactive factor Xa decoy molecule) is provisionally approved for reversal of anticoagulation in patients with life-threatening or uncontrolled bleeding due to rivaroxaban¹ – seek specialist haematologist advice. Although andexanet alfa may reverse the anticoagulant effect of rivaroxaban, achieving haemostasis requires identification and treatment of the source of bleeding.

There is limited evidence on the use of prohaemostatic agents in direct-acting oral anticoagulant (DOAC)–related bleedingTran, 2014. For life-threatening bleeding or emergency surgery, consider the use of prohaemostatic agents, such as prothrombin complex concentrate, if available. Seek specialist haematologist advice; there is a risk of thrombotic complications. See Treatment for apixaban and rivaroxaban poisonings for example prothrombin complex concentrate dosages.

Once bleeding has been managed, whether and when to restart rivaroxaban therapy should be determined in consultation with a specialist.

The combination of rivaroxaban and dual antiplatelet therapy increases the risk of bleeding significantly. If bleeding occurs, consult the patient’s cardiologist before making any change to the antiplatelet therapy.