Information for patients on warfarin who may be eligible for a switch to rivaroxaban/apixaban

People with atrial fibrillation (AF) are at increased risk of having a stroke. If you have AF, your prescriber should assess your individual risk of a stroke, and discuss with you as to whether you should be started on medication to reduce this risk. This leaflet has been devised to provide information in conjunction with the advice from your prescriber.

What is rivaroxaban/Apixaban for?

Rivaroxaban (Xarelto®)/Apixaban (Eliquis®) are anticoagulants (like warfarin) used to lower the risk of blood clots developing in patients who have a condition called atrial fibrillation (an abnormal heart beat) as well as other risk factors for stroke. A blood clot which blocks an artery (blood vessel) is called an embolism. If the embolism occurs in the arteries of the brain, it can cause a stroke. Anticoagulants slow down the time it takes for your blood to clot and reduce the risk of these events happening.

For patients with non-valvular atrial fibrillation, is it worth changing from warfarin?

Warfarin has been prescribed for more than 60 years so there is plenty of experience of its clinical use. The clinical trials showed that rivaroxaban and apixaban are as effective as warfarin. Historically, for patients whose warfarin was well controlled, we previously advised there was no need to change, but the latest NHS advice is that rivaroxaban and apixaban should be used in preference to Warfarin. For patients who have poor anticoagulant control, a switch to rivaroxaban/apixaban is recommended.

Does rivaroxaban/apixaban cause less bleeding than warfarin?

As rivaroxaban, apixaban and warfarin affect blood clotting, patients may still experience side effects such as bruising and bleeding. Intracranial bleeding (bleeding into the brain) is worrying because it is usually very serious. In the clinical trial, rivaroxaban and apixaban caused less intracranial bleeding than warfarin.

Gastrointestinal (stomach and bowel) bleeding is also a concern as it varies widely in terms of severity and is more common. In the clinical trials, rivaroxaban and apixaban caused slightly more gastrointestinal symptoms than warfarin (e.g., indigestion, stomach ache). There was also slightly more epistaxis (nose bleeds) and haematuria (blood in the urine) with rivaroxaban and apixaban compared to warfarin.

If a patient has excessive bleeding, can the anticoagulant effect of rivaroxaban and apixaban be reversed?

There is a licensed product currently available to reverse bleeding with rivaroxaban or apixaban. However, if urgent treatment is required, rivaroxaban/apixaban will be discontinued and supportive measures will be started.

Are regular blood tests needed to monitor rivaroxaban and apixaban levels?

There is no need for regular INR blood tests to measure the level of anticoagulant control with rivaroxaban and apixaban. However, a blood test is needed to measure how well the kidneys are working before starting treatment and then at least once a year whilst on rivaroxaban or apixaban treatment, it is also important to check your weight at least once a year. See this Patient Card for more details on monitoring whilst on this medication.

Which is better, rivaroxaban or apixaban?

There have been no head to head studies comparing these two medications, but the real world evidence seems to suggest that apixaban might have slightly lower risk of bleeding, particularly in older patients. The choice for each patient is whether they feel they are able to take a drug twice a day that maybe be slightly safer, or a drug once a day with food. What is probably most important is agreeing to take a drug that you can take consistently as per the dosage instructions as there is evidence that missing doses significantly increases the risk of stroke.

When and how do I take this medicine?

Always take this medicine as your prescriber has told you. If you do not take rivaroxaban regularly it will not be effective and your risk of a clot forming will increase. The dose is usually 20mg once a day. This dose may be reduced to 15mg once a day if you have kidney problems, are taking other medicines which interact or have a higher risk of bleeding. Your doctor will discuss this with you.

Rivaroxaban should always be taken with a meal preferably with water. Rivaroxaban may be re-dispensed into a compliance aid if necessary.

For Apixaban the usual dose is 5mg TWICE a day and for some people the dose may be reduced to 2.5mg TWICE a day if you have kidney problems, are taking medicines which interact or have a higher risk of bleeding.

It doesn’t matter whether you take apixaban with food or on an empty stomach. Apixaban may be re-dispensed into a compliance aid if necessary.

What are the possible side effects of these medicine?

As these medicines affects blood clotting, most side effects are related to signs such as bruising or bleeding. Tell your doctor immediately if you experience any of the following side effects: Long or excessive bleeding, exceptional weakness, tiredness, paleness, dizziness, headache or unexplained swelling. Also report if there is any blood in the urine or passing black tarry or blood stained stools. Patients should seek urgent medical attention if they fall or injure themselves during treatment, especially if they hit their head, due to the increased risk of bleeding.

What should I do if I forget to take a dose?

It is important not to skip doses. If a dose is missed the patient should take rivaroxaban /apixaban 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.

What should I do if I take too many tablets?

If you have taken too many tablets all at once, you may have an increased risk of bleeding. Contact your doctor or local hospital casualty department at once. Show the doctor your pack of tablets.

How do I store my tablets?

Do not take your tablets if the expiry date has passed. Keep the tablets in their original packaging and store them in a dry place below 25C. Keep all medicines well out of the reach of children – it is best to lock them in a cupboard or medicine cabinet.

Will rivaroxaban/apixaban interact with other medicines, food or alcohol?

Rivaroxaban/apixaban have fewer potential interactions with other medicines compared with warfarin, and at present there are no known interactions with specific foods or alcohol. There are some medicines that rivaroxaban/apixaban does interact with so patients should inform their prescriber of the names of all medicines they are taking (including prescription and over-the-counter medicines, vitamins and herbal supplements)

Should patients stop taking rivaroxaban/apixaban if they are going to have a dental or medical procedure?

Patients should not stop taking rivaroxaban without first talking to their doctor or dentist. Rivaroxaban may need to be stopped for one or more days before any planned surgery, dental or medical procedure.

All patients should be given the rivaroxaban or apixaban alert card and counseled on the details. This should be carried with them at all times.

Once you have reviewed the information at your next INR test, please inform the Phlebotomist/Healthcare Assistant that you are happy to proceed with a transition to rivaroxaban or apixaban.

If you have any further questions, please get back in touch.

Beacon Medical Group

Further Information

Atrial Fibrillation (AF) Alliance Website

British Heart Foundation: What are direct oral anticoagulants (DOACs) and how do they work?

DOAC-Therapy-book.pdf

Apixaban Patient Alert Card

Rivaroxaban Patient Alert Card