Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome

Rivaroxaban (Xarelto, Bayer), co‑administered with aspirin alone or with aspirin plus clopidogrel or ticlopidine, is indicated for the prevention of atherothrombotic events in adult patients after an acute coronary syndrome with elevated cardiac biomarkers. The licensed dose is 2.5 mg twice daily. Patients should also take a daily dose of 75 to 100 mg aspirin or a daily dose of 75 to 100 mg aspirin in addition to either a daily dose of 75 mg clopidogrel or a standard daily dose of ticlopidine. Ticlopidine is not listed in the BNF.

Treatment with rivaroxaban should be evaluated regularly in the individual patient, weighing the risk for ischaemic events against the bleeding risks. Extension of treatment beyond 12 months should be done on an individual patient basis because experience up to 24 months is limited. Treatment with rivaroxaban should be started as soon as possible after stabilisation of the acute coronary syndrome event (including revascularisation procedures); at the earliest 24 hours after admission to hospital and at the time when parenteral anticoagulation therapy would normally be discontinued.

The summary of product characteristics includes the following adverse reactions for rivaroxaban: anaemia, dizziness, headache, fainting, bleeding events, tachycardia (rapid heartbeat), low blood pressure, haematoma, stomach pain, dyspepsia (heartburn), nausea, constipation, diarrhoea, vomiting, pruritus (itching), rash, bruising, pain in the extremities, fever, and swelling, especially of the ankles and feet. For full details of adverse reactions and contraindications, see the summary of product characteristics.

The list price of rivaroxaban is £58.88 per 2.5 mg, 56 capsule pack (excluding VAT, company submission) The recommended dose is 2.5 mg twice daily which equates to a price of £2.10 per day. Total acquisition costs depend on the duration of therapy. Assuming a treatment duration of 12 months, total acquisition costs are £766.50. Costs may vary in different settings because of negotiated procurement discounts.