Patients should be reviewed and the following contra-indications, cautions, drug interactions and counselling points should be checked at initiation of therapy and annually thereafter.
There is no formal tool to assess bleeding risk with rivaroxaban 2.5mg for this indication. Therefore risks and benefits of treatment should be reviewed and referral to secondary care considered if any concerns around continuing therapy (see below).
Review should include FBC to check Hb and haematocrit to detect any occult bleeding. The patient should be asked about any signs of bleeding including epistaxis, gingival, gastro-intestinal and genito-urinary.
Contra-indications (do NOT prescribe rivaroxaban):
- Clinically significant active bleeding (resulting in Hb drop)
- Current or recent GI ulcers
- Malignant neoplasms at high risk of bleeding
- Recent brain or spinal injury or surgery
- Recent ophthalmic surgery
- Recent intracranial haemorrhage
- Known or suspected oesophageal varices
- Arteriovenous malformations
- Vascular aneurysms
- Cirrhotic patients with a Childs-Pugh score of B or C
- Pregnancy and breast feeding
- Previous stroke or TIA
- Creatinine clearance less than 15mL/min
Cautions (review risks and benefits of initiating or continuing therapy, consider referral back to secondary care)
- Congenital or acquired bleeding disorders
- Inflammatory bowel disease; oesophagitis; gastritis; GORD; previous gastroduodenal ulcer or GI bleed
- On concomitant medicines increasing risk of GI bleed (see below and BNF)
- Old age/frailty with multiple co-morbidities: consider GI protection in these patients.
- Bronchiectasis or history of pulmonary bleeding
- Uncontrolled hypertension with systolic BP greater than 160mmHg
- Previous major bleed
- Renal disease with Creatinine less than 200 micromol/L
See gastro-protection guidance for patients on dual anti-platelet therapy, which could also be extrapolated for this treatment combination.
Assess individually; consider whether interacting medicine can be reviewed, refer back to secondary care if already on dual antiplateley therapy (DAPT) or anticoagulation to confirm that combination should be continued.
Note this list is not comprehensive, also refer to BNF or Stockley’s Drug Interactions (www.medicinescomplete.com – no login required on NHS computers)
- Other anticoagulant therapy
- Patients already receiving DAPT
- Patients taking azole antifungals (e.g. ketoconazole, itraconazole, posaconazole, voriconazole) – these can increase the concentration of rivaroxaban and increase risk of bleeding
- SSRIs and SNRIs (inhibitor platelet aggregation)
- Ensure taken with food
- Review and optimise other secondary preventative measures for PAD/CAD including smoking cessation, diet, use of lipid lowering agents and blood pressure control.