Rivaroxaban for Pulmonary Embolism: One pill and done?
By Prathap Sooriyakumaran, MD and Jeffrey Tabas, MD
UCSF-SFGH Emergency Medicine
Rivaroxaban (Xarelta) is a Xa inhibitor that seems to blow coumadin out of the water! Oral, fixed dose, no blood levels to monitor, and recently approved by the FDA for venous thromboembolism (VTE) treatment. Is it THAT good?
The FDA approval was largely based on EINSTEIN-PE , a randomized, open label study with 4,832 PE patients published in the NEJM in 2012. It compared rivaroxaban (15 mg twice daily for 3 weeks, followed by 20 mg once daily) to standard treatment (bridging enoxaparin plus coumadin for 3, 6 or 12 months). The results showed that rivaroxaban was as good as enoxaparin plus coumadin for safety and efficacy.
Should we use rivaroxaban for treatment of PE instead of coumadin with bridging enoxaparin?
The data looks pretty good to us although with some important caveats.
Our back-of-the-envelope calculation using online pharmacy costs is that rivaroxaban for 6 months is roughly 3-4 times the cost of warfarin + bridging enoxaparin, including lab costs.
Ultimate question Based on this information, which therapy would YOU choose for yourself, if faced with a diagnosis of PE?
While acknowledging that further studies may change our knowledge of this medication significantly, based on current data, we would use it -- assuming we are not the ones paying for it!
If we were paying for it out of pocket, we think the benefit over coumadin is minimal and would choose coumadin. That being said, neither of the authors have had to be anticoagulated, so we can’t say for sure.
What would you do?
Drs. Sooriyakumaran and Tabas have no financial disclosures.