Don't Suggest Xarelto for Most Coronary or Peripheral Artery Disease Patients

You'll hear debate about adding Xarelto (rivaroxaban) to aspirin for stable coronary artery disease (CAD) or peripheral artery disease (PAD).

In fact, there's a new Xarelto 2.5 mg tablet...approved by Health Canada to be given twice daily WITH low-dose aspirin to reduce CV events in patients with chronic CAD, with or without PAD.

You may hear reps call this the "vascular" dose of Xarelto...versus the 10, 15, and 20 mg doses for venous thromboembolism or atrial fib.

But don't recommend adding Xarelto to aspirin in most chronic, stable CAD patients, with or without PAD. The margin of benefit is small, and there are risks.

For example, 71 stable CAD patients need to be treated with Xarelto and aspirin for 2 years to prevent one stroke, heart attack, or CV death.

CV benefits are similar in the combo prevents a severe complication, such as amputation, in one in 147 stable PAD patients.

But the combo leads to major bleeding in about one in 80 CAD or PAD patients. And there isn't evidence in patients at high bleeding risk or taking other antithrombotics (clopidogrel, warfarin, etc).

Plus Xarelto 2.5 mg BID costs over $90/month.

Stick with aspirin 81 mg/day for most stable CAD patients, with or without PAD. Also focus on managing risk factors...such as hypertension, dyslipidemia, diabetes, and smoking. For example, ensure patients with CAD are on a statin (atorvastatin 80 mg/day, etc).

Emphasize med adherence and encourage activity...cardiac rehab, a structured exercise program, or simply walking most days of the week.

Advise saving Xarelto 2.5 mg BID as an add-on for the rare patient at high CV risk who has maximized lifestyle adherent to optimized CV meds...and has low bleeding risk. Weigh patient preferences.

Be aware, there isn't evidence for using other direct oral anticoagulants (DOACs)...Eliquis (apixaban), stable CAD or PAD.

Listen to PL Voices to hear our team discuss risks and benefits of Xarelto in stable CAD or PAD patients. And use our chart, Comparison of Oral Anticoagulants, for details about Xarelto and other DOACs.

Key References

  • Lancet 2018;391(10117):219-29
  • Lancet 2018;391(10117):205-18
  • Lancet 2018;391(10117):181-2
  • N Engl J Med 2017;377(14):1319-30
Pharmacist's Letter Canada. Dec 2018, No. 341221

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