`These highlights do not include all the information needed to use
`XARELTO® (rivaroxaban) safely and effectively. See full prescribing
`information for XARELTO.
`XARELTO (rivaroxaban) tablets, for oral use
`Initial U.S. Approval: 2011
`
`WARNING: (A) PREMATURE DISCONTINUATION OF XARELTO
`INCREASES THE RISK OF THROMBOTIC EVENTS,
`(B) SPINAL/EPIDURAL HEMATOMA
`See full prescribing information for complete boxed warning.
`
`
`(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. To reduce this risk,
`consider coverage with another anticoagulant if XARELTO is
`discontinued for a reason other than pathological bleeding or completion
`of a course of therapy. (2.2, 2.3, 5.1, 14.1)
`(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. (5.2, 5.3, 6.2)
`Monitor patients frequently for signs and symptoms of neurological
`impairment and if observed, treat urgently. Consider the benefits and
`risks before neuraxial intervention in patients who are or who need to be
`anticoagulated. (5.3)
`----------------------------RECENT MAJOR CHANGES--------------------------
`Indications and Usage (1.6)
`10/2019
`Indications and Usage (1.7)
`10/2018
`Dosage and Administration (2.1)
`10/2019
`Dosage and Administration (2.4)
`10/2018
`Warnings and Precautions (5.2, 5.4)
`10/2019
`Warnings and Precautions (5.10)
`10/2019
`----------------------------INDICATIONS AND USAGE---------------------------
`XARELTO is a factor Xa inhibitor indicated:
`
`to reduce the risk of stroke and systemic embolism in patients with
`nonvalvular atrial fibrillation (1.1)
`for the treatment of deep vein thrombosis (DVT) (1.2)
`for the treatment of pulmonary embolism (PE) (1.3)
`for the reduction in the risk of recurrence of DVT and/or PE in patients
`at continued risk for recurrent DVT and/or PE after completion of initial
`treatment lasting at least 6 months (1.4)
`for the prophylaxis of DVT, which may lead to PE in patients
`undergoing knee or hip replacement surgery (1.5)
`for the prophylaxis of venous thromboembolism (VTE) in acutely ill
`medical patients at risk for thromboembolic complications not at high
`risk of bleeding (1.6, 5.2)
`in combination with aspirin, to reduce the risk of major cardiovascular
`events (cardiovascular (CV) death, myocardial infarction (MI) and
`stroke) in patients with chronic coronary artery disease (CAD) or
`peripheral artery disease (PAD) (1.7)
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`-----------------------DOSAGE AND ADMINISTRATION-----------------------
`
`Nonvalvular Atrial Fibrillation:
`o For patients with CrCl >50 mL/min: 20 mg orally, once daily with
`the evening meal (2.1)
`o For patients with CrCl ≤50 mL/min: 15 mg orally, once daily with
`the evening meal (2.1)
`Treatment of DVT and/or PE: 15 mg orally twice daily with food for the
`first 21 days followed by 20 mg orally once daily with food for the
`remaining treatment (2.1)
`Reduction in the Risk of Recurrence of DVT and/or PE in patients at
`continued risk for DVT and/or PE: 10 mg once daily with or without
`food, after at least 6 months of standard anticoagulant treatment (2.1)
`Prophylaxis of DVT Following Hip or Knee Replacement Surgery:
`10 mg orally once daily with or without food (2.1)
`Prophylaxis of VTE in Acutely Ill Medical Patients at Risk for
`Thromboembolic Complications Not at High Risk of Bleeding: 10 mg
`once daily, with or without food, in hospital and after hospital discharge
`for a total recommended duration of 31 to 39 days (2.1)
`Reduction of Risk of Major Cardiovascular Events (CV Death, MI, and
`Stroke) in chronic CAD or PAD: 2.5 mg orally twice daily, with or
`without food, in combination with aspirin (75-100 mg) once daily (2.1)
`--------------------DOSAGE FORMS AND STRENGTHS----------------------
`Tablets: 2.5 mg, 10 mg, 15 mg, and 20 mg (3)
`-------------------------------CONTRAINDICATIONS------------------------------
`
`Active pathological bleeding (4)
`
`Severe hypersensitivity reaction to XARELTO (4)
`---------------------------WARNINGS AND PRECAUTIONS-------------------
`
`Risk of bleeding: XARELTO can cause serious and fatal bleeding.
`Promptly evaluate signs and symptoms of blood loss. An agent to
`reverse the anti-factor Xa activity of rivaroxaban is available. (5.2)
`Pregnancy-related hemorrhage: Use XARELTO with caution in
`pregnant women due to the potential for obstetric hemorrhage and/or
`emergent delivery. Promptly evaluate signs and symptoms of blood loss.
`(5.7)
`Prosthetic heart valves: XARELTO use not recommended (5.8)
`Increased Risk of Thrombosis in Patients with Triple Positive
`Antiphospholipid Syndrome: XARELTO use not recommended. (5.10)
`------------------------------ADVERSE REACTIONS------------------------------
`The most common adverse reaction (>5%) was bleeding. (6.1)
`To report SUSPECTED ADVERSE REACTIONS, contact Janssen
`Pharmaceuticals, Inc. at 1-800-526-7736 or FDA at 1-800-FDA-1088 or
`www.fda.gov/medwatch.
`---------------------------------DRUG INTERACTIONS----------------------------
`
`Combined P-gp and strong CYP3A inhibitors and inducers: Avoid
`concomitant use (7.2, 7.3)
`
`Anticoagulants: Avoid concomitant use (7.4)
`-----------------------USE IN SPECIFIC POPULATIONS-----------------------
`
`Renal impairment: Avoid or adjust dose based on CrCl and
`Indication (8.6)
`Hepatic impairment: Avoid use in patients with Child-Pugh B and C
`hepatic impairment or with any degree of hepatic disease associated with
`coagulopathy (8.7)
`See 17 for PATIENT COUNSELING INFORMATION and Medication
`Guide.
`
`
`
`
`
`
`
`
`
`FULL PRESCRIBING INFORMATION: CONTENTS*
`
`WARNING: (A) PREMATURE DISCONTINUATION OF
`XARELTO INCREASES THE RISK OF THROMBOTIC
`EVENTS, (B) SPINAL/EPIDURAL HEMATOMA
`INDICATIONS AND USAGE
`1.1 Reduction of Risk of Stroke and Systemic
`Embolism in Nonvalvular Atrial Fibrillation
`1.2 Treatment of Deep Vein Thrombosis
`1.3 Treatment of Pulmonary Embolism
`1.4 Reduction in the Risk of Recurrence of Deep
`Vein Thrombosis and/or Pulmonary Embolism
`
`1
`
`Reference ID: 4505347
`
`
`
`Revised: 10/2019
`
`
`1.5 Prophylaxis of Deep Vein Thrombosis Following
`Hip or Knee Replacement Surgery
`1.6 Prophylaxis of Venous Thromboembolism in
`Acutely Ill Medical Patients at Risk for
`Thromboembolic Complications Not at High Risk
`of Bleeding
`1.7 Reduction of Risk of Major Cardiovascular Events
`in Patients with Chronic Coronary Artery Disease
`(CAD) or Peripheral Artery Disease (PAD)
`2 DOSAGE AND ADMINISTRATION
`2.1 Recommended Dosage
`2.2 Switching to and from XARELTO
`
`
`
`
`
`
`
`2.3 Discontinuation for Surgery and other
`Interventions
`2.4 Missed Dose
`2.5 Administration Options
`3 DOSAGE FORMS AND STRENGTHS
`4 CONTRAINDICATIONS
`5 WARNINGS AND PRECAUTIONS
`5.1
`Increased Risk of Thrombotic Events after
`Premature Discontinuation
`5.2 Risk of Bleeding
`5.3 Spinal/Epidural Anesthesia or Puncture
`5.4 Use in Patients with Renal Impairment
`5.5 Use in Patients with Hepatic Impairment
`5.6 Use with P-gp and Strong CYP3A Inhibitors or
`Inducers
`5.7 Risk of Pregnancy-Related Hemorrhage
`5.8 Patients with Prosthetic Heart Valves
`5.9 Acute PE in Hemodynamically Unstable Patients
`or Patients Who Require Thrombolysis or
`Pulmonary Embolectomy
`5.10
`Increased Risk of Thrombosis in Patients with
`Triple Positive Antiphospholipid Syndrome
`6 ADVERSE REACTIONS
`6.1 Clinical Trials Experience
`6.2 Postmarketing Experience
`7 DRUG INTERACTIONS
`7.1 General Inhibition and Induction Properties
`7.2 Drugs that Inhibit Cytochrome P450 3A Enzymes
`and Drug Transport Systems
`7.3 Drugs that Induce Cytochrome P450 3A
`Enzymes and Drug Transport Systems
`7.4 Anticoagulants and NSAIDs/Aspirin
`8 USE IN SPECIFIC POPULATIONS
`8.1 Pregnancy
`
`
`
`
`
`
`Lactation
`8.2
`8.3 Females and Males of Reproductive Potential
`8.4 Pediatric Use
`8.5 Geriatric Use
`8.6 Renal Impairment
`8.7 Hepatic Impairment
`10 OVERDOSAGE
`11 DESCRIPTION
`12 CLINICAL PHARMACOLOGY
`12.1 Mechanism of Action
`12.2 Pharmacodynamics
`12.3 Pharmacokinetics
`12.6 QT/QTc Prolongation
`13 NON-CLINICAL TOXICOLOGY
`13.1 Carcinogenesis, Mutagenesis, Impairment of
`Fertility
`14 CLINICAL STUDIES
`14.1 Stroke Prevention in Nonvalvular Atrial Fibrillation
`14.2 Treatment of Deep Vein Thrombosis (DVT)
`and/or Pulmonary Embolism (PE)
`14.3 Reduction in the Risk of Recurrence of DVT
`and/or PE
`14.4 Prophylaxis of Deep Vein Thrombosis Following
`Hip or Knee Replacement Surgery
`14.5 Prophylaxis of Venous Thromboembolism in
`Acutely Ill Medical Patients at Risk for
`Thromboembolic Complications Not at High Risk
`of Bleeding
`14.6 Reduction of Risk of Major Cardiovascular Events
`in Patients with Chronic CAD or PAD
`16 HOW SUPPLIED/STORAGE AND HANDLING
`17 PATIENT COUNSELING INFORMATION
`
`
`*Sections or subsections omitted from the full prescribing information are not
`listed.
`
`
`
`
`
`
`
`Reference ID: 4505347
`
`
`
`
`
`
`FULL PRESCRIBING INFORMATION
`
`
`WARNING: (A) PREMATURE DISCONTINUATION OF XARELTO INCREASES THE
`RISK OF THROMBOTIC EVENTS,
`(B) SPINAL/EPIDURAL HEMATOMA
`
`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 Dosage and Administration (2.2, 2.3), Warnings and
`Precautions (5.1), and Clinical Studies (14.1)].
`
`
`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 Warnings and Precautions (5.2, 5.3) and Adverse Reactions (6.2)].
`
`Monitor patients frequently for signs and symptoms of neurological impairment. If
`neurological compromise is noted, urgent treatment is necessary [see Warnings and
`Precautions (5.3)].
`
`Consider the benefits and risks before neuraxial intervention in patients anticoagulated or
`to be anticoagulated for thromboprophylaxis [see Warnings and Precautions (5.3)].
`
` 1
`
`INDICATIONS AND USAGE
`
`1.1 Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation
`XARELTO is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial
`fibrillation.
`
`There are limited data on the relative effectiveness of XARELTO and warfarin in reducing the risk of stroke and
`systemic embolism when warfarin therapy is well-controlled [see Clinical Studies (14.1)].
`
`
`
`Reference ID: 4505347
`
`
`
`
`1.2 Treatment of Deep Vein Thrombosis
`XARELTO is indicated for the treatment of deep vein thrombosis (DVT).
`
`1.3 Treatment of Pulmonary Embolism
`XARELTO is indicated for the treatment of pulmonary embolism (PE).
`
`1.4 Reduction in the Risk of Recurrence of Deep Vein Thrombosis and/or Pulmonary
`Embolism
`XARELTO is indicated for the reduction in the risk of recurrence of DVT and/or PE in patients at continued risk
`for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months.
`
`1.5 Prophylaxis of Deep Vein Thrombosis Following Hip or Knee Replacement Surgery
`XARELTO is indicated for the prophylaxis of DVT, which may lead to PE in patients undergoing knee or hip
`replacement surgery.
`
`1.6 Prophylaxis of Venous Thromboembolism in Acutely Ill Medical Patients at Risk for
`Thromboembolic Complications Not at High Risk of Bleeding
`XARELTO is indicated for the prophylaxis of venous thromboembolism (VTE) and VTE related death during
`hospitalization and post hospital discharge in adult patients admitted for an acute medical illness who are at risk
`for thromboembolic complications due to moderate or severe restricted mobility and other risk factors for VTE
`and not at high risk of bleeding [see Warnings and Precautions (5.2) and Clinical Studies (14.1)].
`
`1.7 Reduction of Risk of Major Cardiovascular Events in Patients with Chronic Coronary
`Artery Disease (CAD) or Peripheral Artery Disease (PAD)
`XARELTO, in combination with aspirin, is indicated to reduce the risk of major cardiovascular events
`(cardiovascular (CV) death, myocardial infarction (MI) and stroke) in patients with chronic coronary artery
`disease (CAD) or peripheral artery disease (PAD).
`
`Reference ID: 4505347
`
`
`
`
`
`
`2 DOSAGE AND ADMINISTRATION
`2.1 Recommended Dosage
`Table 1:
`Recommended Dosage
`Indication
`Renal
`Considerations*
`CrCl >50 mL/min
`
`CrCl ≤50 mL/min
`
`CrCl ≥30 mL/min
`
`Dosage
`
`20 mg once daily
`
`15 mg once daily
`
`15 mg twice daily
`▼ after 21 days, transition to ▼
`20 mg once daily
`
`CrCl <30 mL/min
`
`Avoid Use
`
`Food/Timing†
`
`Take with evening meal
`
`Take with evening meal
`
`Take with food,
`at the same time each day
`
`Reduction in Risk of
`Stroke in
`Nonvalvular Atrial
`Fibrillation
`Treatment of DVT
`and/or PE
`
`- Hip
`Replacement
`Surgery‡
`
`- Knee
`Replacement
`Surgery‡
`
`Reduction in the Risk
`of Recurrence of
`DVT and/or PE in
`patients at continued
`risk for DVT and/or
`PE
`Prophylaxis of DVT Following:
`
`
`CrCl ≥30 mL/min
`
`CrCl <30 mL/min
`
`CrCl ≥30 mL/min
`
`CrCl <30 mL/min
`
`CrCl ≥30 mL/min
`
`CrCl <30 mL/min
`
`CrCl ≥30 mL/min
`
`CrCl <30 mL/min
`
`No dose adjustment
`needed based on CrCl
`
`
`10 mg once daily, after at least 6
`months of standard anticoagulant
`treatment
`
`Avoid Use
`
`Take with or without food
`
`10 mg once daily for 35 days, 6-10
`hours after surgery once hemostasis has
`been established
`
`Avoid Use
`
`10 mg once daily for 12 days, 6-10
`hours after surgery once hemostasis has
`been established
`
`Avoid Use
`
`10 mg once daily, in hospital and after
`hospital discharge, for a total
`recommended duration of 31 to
`39 days
`
`Avoid Use
`
`Take with or without food
`
`Take with or without food
`
`Take with or without food
`
`2.5 mg twice daily, plus aspirin (75-
`100 mg) once daily
`
`Take with or without food
`
`Prophylaxis of VTE
`in Acutely Ill Medical
`Patients at Risk for
`Thromboembolic
`Complications Not at
`High Risk of Bleeding
`Reduction of Risk of
`Major
`Cardiovascular
`Events (CV Death,
`MI, and Stroke) in
`Chronic CAD or
`PAD
`*
`†
`‡
`
`
`See Use in Specific Populations (8.6)
`See Clinical Pharmacology (12.3)
`See Dosage and Administration (2.3)
`
`Reference ID: 4505347
`
`
`
`
`
`
`2.2 Switching to and from XARELTO
`Switching from Warfarin to XARELTO - When switching patients from warfarin to XARELTO, discontinue
`warfarin and start XARELTO as soon as the International Normalized Ratio (INR) is below 3.0 to avoid periods
`of inadequate anticoagulation.
`
`Switching from XARELTO to Warfarin - 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. One approach is to discontinue
`XARELTO and begin both a parenteral anticoagulant and warfarin at the time the next dose of XARELTO would
`have been taken.
`
`Switching from XARELTO to Anticoagulants other than Warfarin - For patients currently taking XARELTO and
`transitioning to an anticoagulant with rapid onset, discontinue XARELTO and give the first dose of the other
`anticoagulant (oral or parenteral) at the time that the next XARELTO dose would have been taken [see Drug
`Interactions (7.4)].
`
`Switching from Anticoagulants other than Warfarin to XARELTO - For patients currently receiving an
`anticoagulant other than warfarin, start XARELTO 0 to 2 hours prior to the next scheduled evening administration
`of the drug (e.g., low molecular weight heparin or non-warfarin oral anticoagulant) and omit administration of
`the other anticoagulant. For unfractionated heparin being administered by continuous infusion, stop the infusion
`and start XARELTO at the same time.
`
`2.3 Discontinuation for Surgery and other Interventions
`If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures,
`XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings
`and Precautions (5.2)]. 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. XARELTO
`should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established,
`noting that the time to onset of therapeutic effect is short [see Warnings and Precautions (5.1)]. If oral medication
`cannot be taken during or after surgical intervention, consider administering a parenteral anticoagulant.
`
`2.4 Missed Dose
` For patients receiving 2.5 mg twice daily: if a dose is missed, the patient should take a single 2.5 mg
`XARELTO dose as recommended at the next scheduled time.
` For patients receiving 15 mg twice daily: The patient should take XARELTO immediately to ensure intake of
`30 mg XARELTO per day. Two 15 mg tablets may be taken at once.
` For patients receiving 20 mg, 15 mg or 10 mg once daily: The patient should take the missed XARELTO dose
`immediately. The dose should not be doubled within the same day to make up for a missed dose.
`
`
`
`Reference ID: 4505347
`
`
`
`
`2.5 Administration Options
`For patients who are unable to swallow whole tablets, XARELTO tablets may be crushed and mixed with
`applesauce immediately prior to use and administered orally. After the administration of a crushed XARELTO
`15 mg or 20 mg tablet, the dose should be immediately followed by food [see Clinical Pharmacology (12.3)].
`
`Administration via nasogastric (NG) tube or gastric feeding tube: After confirming gastric placement of the tube,
`XARELTO tablets may be crushed and suspended in 50 mL of water and administered via an NG tube or gastric
`feeding tube. Since rivaroxaban absorption is dependent on the site of drug release, avoid administration of
`XARELTO distal to the stomach which can result in reduced absorption and thereby, reduced drug exposure.
`After the administration of a crushed XARELTO 15 mg or 20 mg tablet, the dose should then be immediately
`followed by enteral feeding [see Clinical Pharmacology (12.3)].
`
`Crushed XARELTO tablets are stable in water and in applesauce for up to 4 hours. An in vitro compatibility study
`indicated that there is no adsorption of rivaroxaban from a water suspension of a crushed XARELTO tablet to
`PVC or silicone nasogastric (NG) tubing.
`
`3 DOSAGE FORMS AND STRENGTHS
` 2.5 mg tablets: Round, light yellow, and film-coated with a triangle pointing down above a “2.5” marked on
`one side and “Xa” on the other side
` 10 mg tablets: Round, light red, biconvex and film-coated with a triangle pointing down above a “10” marked
`on one side and “Xa” on the other side
` 15 mg tablets: Round, red, biconvex, and film-coated with a triangle pointing down above a “15” marked on
`one side and “Xa” on the other side
` 20 mg tablets: Triangle-shaped, dark red, and film-coated with a triangle pointing down above a “20” marked
`on one side and “Xa” on the other side
`
`4 CONTRAINDICATIONS
`XARELTO is contraindicated in patients with:
` active pathological bleeding [see Warnings and Precautions (5.2)]
` severe hypersensitivity reaction to XARELTO (e.g., anaphylactic reactions) [see Adverse Reactions (6.2)]
`5 WARNINGS AND PRECAUTIONS
`5.1
`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. An increased rate of stroke was observed during the
`transition from XARELTO to warfarin in clinical trials in atrial fibrillation patients. If XARELTO is discontinued
`for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another
`anticoagulant [see Dosage and Administration (2.2, 2.3) and Clinical Studies (14.1)].
`
`Reference ID: 4505347
`
`
`
`
`
`
`5.2 Risk of Bleeding
`XARELTO increases the risk of bleeding and can cause serious or fatal bleeding. In deciding whether to prescribe
`XARELTO to patients at increased risk of bleeding, the risk of thrombotic events should be weighed against the
`risk of bleeding.
`
`Promptly evaluate any signs or symptoms of blood loss and consider the need for blood replacement. Discontinue
`XARELTO in patients with active pathological hemorrhage. The terminal elimination half-life of rivaroxaban is
`5 to 9 hours in healthy subjects aged 20 to 45 years.
`
`Concomitant use of other drugs that impair hemostasis increases the risk of bleeding. These include aspirin, P2Y12
`platelet inhibitors, dual antiplatelet therapy, other antithrombotic agents, fibrinolytic therapy, non-steroidal anti-
`inflammatory drugs (NSAIDs) [see Drug Interactions (7.4)], selective serotonin reuptake inhibitors, and
`serotonin norepinephrine reuptake inhibitors.
`
`Concomitant use of drugs that are known combined P-gp and strong CYP3A inhibitors increases rivaroxaban
`exposure and may increase bleeding risk [see Drug Interactions (7.2)].
`
`Risk of Hemorrhage in Acutely Ill Medical Patients at High Risk of Bleeding
`Acutely ill medical patients with the following conditions are at increased risk of bleeding with the use of
`XARELTO for primary VTE prophylaxis: history of bronchiectasis, pulmonary cavitation, or pulmonary
`hemorrhage, active cancer (i.e. undergoing acute, in-hospital cancer treatment), active gastroduodenal ulcer in the
`three months prior to treatment, history of bleeding in the three months prior to treatment, or dual antiplatelet
`therapy. XARELTO is not for use for primary VTE prophylaxis in these hospitalized, acutely ill medical patients
`at high risk of bleeding.
`
`Reversal of Anticoagulant Effect
`An agent to reverse the anti-factor Xa activity of rivaroxaban is available. Because of high plasma protein binding,
`rivaroxaban is not dialyzable [see Clinical Pharmacology (12.3)]. Protamine sulfate and vitamin K are not
`expected to affect the anticoagulant activity of rivaroxaban. Use of procoagulant reversal agents, such as
`prothrombin complex concentrate (PCC), activated prothrombin complex concentrate or recombinant factor VIIa,
`may be considered but has not been evaluated in clinical efficacy and safety studies. Monitoring for the
`anticoagulation effect of rivaroxaban using a clotting test (PT, INR or aPTT) or anti-factor Xa (FXa) activity is
`not recommended.
`
`5.3 Spinal/Epidural Anesthesia or Puncture
`When neuraxial anesthesia (spinal/epidural anesthesia) or spinal puncture is employed, patients treated with
`anticoagulant agents for prevention of thromboembolic complications are at risk of developing an epidural or
`spinal hematoma which can result in long-term or permanent paralysis [see Boxed Warning].
`
`To reduce the potential risk of bleeding associated with the concurrent use of XARELTO and epidural or spinal
`anesthesia/analgesia or spinal puncture, consider the pharmacokinetic profile of XARELTO [see Clinical
`
`
`
`Reference ID: 4505347
`
`
`
`
`Pharmacology (12.3)]. Placement or removal of an epidural catheter or lumbar puncture is best performed when
`the anticoagulant effect of XARELTO is low; however, the exact timing to reach a sufficiently low anticoagulant
`effect in each patient is not known.
`
`An indwelling epidural or intrathecal catheter should not be removed before at least 2 half-lives have elapsed (i.e.,
`18 hours in young patients aged 20 to 45 years and 26 hours in elderly patients aged 60 to 76 years), after the last
`administration of XARELTO [see Clinical Pharmacology (12.3)]. The next XARELTO dose should not be
`administered earlier than 6 hours after the removal of the catheter. If traumatic puncture occurs, delay the
`administration of XARELTO for 24 hours.
`
`Should the physician decide to administer anticoagulation in the context of epidural or spinal anesthesia/analgesia
`or lumbar puncture, monitor frequently to detect any signs or symptoms of neurological impairment, such as
`midline back pain, sensory and motor deficits (numbness, tingling, or weakness in lower limbs), bowel and/or
`bladder dysfunction. Instruct patients to immediately report if they experience any of the above signs or
`symptoms. If signs or symptoms of spinal hematoma are suspected, initiate urgent diagnosis and treatment
`including consideration for spinal cord decompression even though such treatment may not prevent or reverse
`neurological sequelae.
`
`5.4 Use in Patients with Renal Impairment
`Nonvalvular Atrial Fibrillation
`Periodically assess renal function as clinically indicated (i.e., more frequently in situations in which renal function
`may decline) and adjust therapy accordingly [see Dosage and Administration (2.1)]. Consider dose adjustment
`or discontinuation of XARELTO in patients who develop acute renal failure while on XARELTO [see Use in
`Specific Populations (8.6)].
`
`Treatment of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), and Reduction in the Risk of
`Recurrence of DVT and of PE
`Avoid the use of XARELTO in patients with CrCl <30 mL/min due to an expected increase in rivaroxaban
`exposure and pharmacodynamic effects in this patient population [see Use in Specific Populations (8.6)].
`
`Prophylaxis of Deep Vein Thrombosis Following Hip or Knee Replacement Surgery
`Avoid the use of XARELTO in patients with CrCl <30 mL/min due to an expected increase in rivaroxaban
`exposure and pharmacodynamic effects in this patient population. Observe closely and promptly evaluate any
`signs or symptoms of blood loss in patients with CrCl 30 to 50 mL/min. Patients who develop acute renal failure
`while on XARELTO should discontinue the treatment [see Use in Specific Populations (8.6)].
`
`Prophylaxis of Venous Thromboembolism in Acutely Ill Medical Patients at Risk for Thromboembolic
`Complications Not at High Risk of Bleeding
`Avoid the use of XARELTO in patients with CrCl <30 mL/min due to an expected increase in rivaroxaban
`exposure and pharmacodynamic effects in this patient population. Consider discontinuation of XARELTO in
`patients who develop acute renal failure while on XARELTO [see Use in Specific Populations (8.6)].
`
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`Reference ID: 4505347
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`5.5 Use in Patients with Hepatic Impairment
`No clinical data are available for patients with severe hepatic impairment.
`
`Avoid use of XARELTO in patients with moderate (Child-Pugh B) and severe (Child-Pugh C) hepatic impairment
`or with any hepatic disease associated with coagulopathy since drug exposure and bleeding risk may be increased
`[see Use in Specific Populations (8.7)].
`
`5.6 Use with P-gp and Strong CYP3A Inhibitors or Inducers
`Avoid concomitant use of XARELTO with known combined P-gp and strong CYP3A inhibitors [see Drug
`Interactions (7.2)].
`
`Avoid concomitant use of XARELTO with drugs that are known combined P-gp and strong CYP3A inducers
`[see Drug Interactions (7.3)].
`
`5.7 Risk of Pregnancy-Related Hemorrhage
`In pregnant women, XARELTO should be used only if the potential benefit justifies the potential risk to the
`mother and fetus. XARELTO dosing in pregnancy has not been studied. The anticoagulant effect of XARELTO
`cannot be monitored with standard laboratory testing. Promptly evaluate any signs or symptoms suggesting blood
`loss (e.g., a drop in hemoglobin and/or hematocrit, hypotension, or fetal distress) [see Warnings and Precautions
`(5.2)].
`
`5.8 Patients with Prosthetic Heart Valves
`The safety and efficacy of XARELTO have not been studied in patients with prosthetic heart valves. Therefore,
`use of XARELTO is not recommended in these patients.
`
`5.9 Acute PE in Hemodynamically Unstable Patients or Patients Who Require Thrombolysis
`or Pulmonary Embolectomy
`Initiation of XARELTO is not recommended acutely as an alternative to unfractionated heparin in patients with
`pulmonary embolism who present with hemodynamic instability or who may receive thrombolysis or pulmonary
`embolectomy.
`
`5.10 Increased Risk of Thrombosis in Patients with Triple Positive Antiphospholipid
`Syndrome
`Direct-acting oral anticoagulants (DOACs), including XARELTO, are not recommended for use in patients with
`triple-positive antiphospholipid syndrome (APS). For patients with APS (especially those who are triple positive
`[positive for lupus anticoagulant, anticardiolipin, and anti-beta 2-glycoprotein I antibodies]), treatment with
`DOACs has been associated with increased rates of recurrent thrombotic events compared with vitamin K
`antagonist therapy.
`
`Reference ID: 4505347
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`6 ADVERSE REACTIONS
`The following clinically significant adverse reactions are also discussed in other sections of the labeling:
`
`
`
`Increased Risk of Stroke After Discontinuation in Nonvalvular Atrial Fibrillation [see Boxed Warning and
`Warnings and Precautions (5.1)]
` Bleeding Risk [see Warnings and Precautions (5.2, 5.4, 5.5, 5.6, 5.7)]
` Spinal/Epidural Hematoma [see Boxed Warning and Warnings and Precautions (5.3)]
`6.1 Clinical Trials Experience
`Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the
`clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not
`reflect the rates observed in clinical practice.
`
`During clinical development for the approved indications, 31,691 patients were exposed to XARELTO. These
`included 7111 patients who received XARELTO 15 mg or 20 mg orally once daily for a mean of 19 months (5558
`for 12 months and 2512 for 24 months) to reduce the risk of stroke and systemic embolism in nonvalvular atrial
`fibrillation (ROCKET AF); 6962 patients who received XARELTO 15 mg orally twice daily for three weeks
`followed by 20 mg orally once daily to treat DVT or PE (EINSTEIN DVT, EINSTEIN PE), 10 mg or 20 mg
`orally once daily (EINSTEIN Extension, EINSTEIN CHOICE) to reduce the risk of recurrence of DVT and/or
`PE; 4487 patients who received XARELTO 10 mg orally once daily for prophylaxis of DVT following hip or
`knee replacement surgery (RECORD 1-3); 3997 patients who received 10 mg orally once daily for prophylaxis
`of VTE and VTE-related death in acutely ill medical patients (MAGELLAN) and 9134 patients who received
`XARELTO 2.5 mg orally twice daily, in combination with aspirin 100 mg once daily, for the reduction in risk of
`major cardiovascular events in patients with chronic CAD or PAD (COMPASS).
`
`Hemorrhage
`The most common adverse reactions with XARELTO were bleeding complications [see Warnings and
`Precautions (5.2)].
`
`Nonvalvular Atrial Fibrillation
`In the ROCKET AF trial, the most frequent adverse reactions associated with permanent drug discontinuation
`were bleeding events, with incidence rates of 4.3% for XARELTO vs. 3.1% for warfarin. The incidence of
`discontinuations for non-bleeding adverse events was similar in both treatment groups.
`
`Table 2 shows the number of patients experiencing various types of bleeding events in the ROCKET AF trial.
`
`
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`Reference ID: 4505347
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`Bleeding Events in ROCKET AF*- On Treatment Plus 2 Days
`Table 2:
`Parameter
`XARELTO
`Warfarin
`N=7111
`N=7125
`n (%/year)
`n (%/year)
`395 (3.6)
`386 (3.5)
`55 (0.5)
`84 (0.7)
`
`Major Bleeding†
`Intracranial Hemorrhage
`(ICH) ‡
`58 (0.5)
`36 (0.3)
`Hemorrhagic Stroke§
`26 (0.2)
`19 (0.2)
`Other ICH
`140 (1.2)
`221 (2.0)
`Gastrointestinal (GI)¶
`55 (0.5)
`27 (0.2)
`Fatal Bleeding#
`42 (0.4)
`24 (0.2)
`ICH
`13 (0.1)
`3 (0.0)
`Non-intracranial
`Abbreviations: HR = Hazard Ratio, CI = Confidence interval, CRNM = Clinically Relevant Non-Major.
`* Major bleeding events within each s