Xarelto

Xarelto is an anticoagulant medicine (a medicine that prevents blood clotting) used in adults:

• to prevent venous thromboembolism (VTE, the formation of blood clots in the veins) in patients who are undergoing surgery to replace a hip or knee;
• to prevent stroke (caused by a blood clot in the brain) and systemic embolism (a blood clot in another organ) in patients with non-valvular atrial fibrillation (irregular rapid contractions of the upper chambers of the heart);
• to treat deep vein thrombosis (DVT, a blood clot in a deep vein, usually in the leg) and pulmonary embolism (a clot in a blood vessel supplying the lungs), and to prevent DVT and pulmonary embolism from re-occuring.
• to prevent atherothrombotic events (problems caused by blood clots and hardening of the arteries) after an acute coronary syndrome. Acute coronary syndrome is a group of conditions that includes unstable angina (a severe type of chest pain) and heart attack. Xarelto is used together with antiplatelet medicines, which prevent the formation of blood clots.

Xarelto contains the active substance rivaroxaban.

Xarelto is available as tablets (2.5, 10, 15 and 20 mg). To prevent VTE in patients undergoing hip or knee replacement surgery, the recommended dose of Xarelto is 10 mg once daily. Treatment is continued for 5 weeks in patients who have had hip replacement surgery, and for 2 weeks in patients who have had knee replacement surgery.

To prevent stroke or systemic embolism in patients with non-valvular atrial fibrillation, the recommended dose of Xarelto is 20 mg once daily. Treatment should be continued long term provided that the benefit outweighs the risk of bleeding.

To treat DVT and pulmonary embolism or to prevent DVT and pulmonary embolism from occurring again, the recommended starting dose of Xarelto is 15 mg twice daily for 3 weeks followed by 20 mg once daily. If treatment is continued longer than 6 months, the dose may be reduced to 10 mg once daily.

To prevent atherothrombotic events in patients who have had acute coronary syndrome, the recommended dose of Xarelto is 2.5 mg twice daily. It should be taken in combination with aspirin, or with aspirin and clopidogrel, or with aspirin and ticlopidine. The doctor will regularly evaluate the benefits of ongoing treatment against the risk of excessive or internal bleeding.

The medicine can only be obtained with a prescription. For further information, see the package leaflet.

The active substance in Xarelto, rivaroxaban, is a ‘factor Xa inhibitor’. This means that it blocks factor Xa, an enzyme that is involved in the production of thrombin. Thrombin is central to the process of blood clotting. By blocking factor Xa, the levels of thrombin decrease, which reduces the risk of blood clots forming in the veins and arteries, and also treats existing clots.

Prevention of VTE after surgery

For the prevention of VTE after surgery, Xarelto was shown to be more effective than enoxaparin (another anticoagulant medicine) in preventing blood clots or death in three main studies, two in patients undergoing hip replacement surgery and one in patients undergoing knee replacement surgery:

• The first study compared Xarelto with enoxaparin, each given for 5 weeks in around 4,500 patients undergoing hip replacement surgery. Results showed that 1% of the patients who completed treatment with Xarelto had blood clots or died (18 out of 1,595), compared with 4% of the patients receiving enoxaparin (58 out of 1,558).
• The second study also in hip replacement surgery patients compared Xarelto given for 5 weeks with enoxaparin given for 2 weeks in around 2,500 patients. Results showed that 2% of the patients taking Xarelto had blood clots or died (17 out of 864), compared with 9% of the patients receiving enoxaparin (81 out of 869).
• The third study compared Xarelto with enoxaparin, each given for 2 weeks in around 2,500 patients undergoing knee replacement surgery. Results showed that 10% of the patients receiving Xarelto had blood clots or died (79 out of 824), compared with 19% of the patients receiving enoxaparin (166 out of 878).

Prevention of stroke and systemic embolism

For the prevention of stroke and systemic embolism, Xarelto was compared with warfarin (another anticoagulant medicine) in one main study in over 14,000 patients with non-valvular atrial fibrillation. Results showed that 2.7% (188 out of 6958) of patients taking Xarelto had a stroke or a blood clot, compared with 3.4% (241 out of 7004) of patients taking warfarin.

Treatment and prevention of DVT and pulmonary embolism

For DVT and pulmonary embolism, Xarelto was compared with enoxaparin given in combination with a vitamin K antagonist, VKA (a class of anticoagulants such as warfarin), in two main studies in around 3,400 patients with acute DVT and around 4,800 patients with pulmonary embolism. In the study in patients with acute DVT, 2.1% (36 out of 1,731) of patients treated with Xarelto had either DVT again or pulmonary embolism, compared with 3.0% (51 out of 1,718) of patients receiving enoxaparin and VKA. In the study in patients with pulmonary embolism, 2.1% (50 out of 2,419) of patients treated with Xarelto had either DVT or pulmonary embolism again, compared with 1.8% (44 out of 2,413) of patients receiving enoxaparin and VKA.

An additional study involved over 3,000 patients who had completed 6 to 12 months of treatment for DVT and pulmonary embolism. Patients received either 10 mg or 20 mg Xarelto daily, or 100 mg aspirin daily for an additional 12 months. Results showed that 1.5% of patients in the Xarelto 20 mg group, 1.2% of patients in the Xarelto 10 mg group and 4.4% of patients in the aspirin 100 mg group had DVT or pulmonary embolism again or died.

Prevention of atherothrombotic events

For the prevention of atherothrombotic events in patients with acute coronary syndrome, Xarelto was compared with placebo (a dummy treatment) in one main study involving over 15,000 patients who had recently had an acute coronary syndrome. All patients also received standard antiplatelet medicines. In the study in patients who have had acute coronary syndrome, 6.1% (313 out of 5,114) of patients treated with Xarelto had an ‘event’ such as a heart attack, stroke or death due to heart problems during the study, compared with 7.4% (376 out of 5,113) of patients receiving placebo.

The most common side effects with Xarelto (seen in between 1 and 10 patients in 100) are bleeding in various parts of the body, anaemia, dizziness, headache, hypotension (low blood pressure), haematoma (collection of blood under the skin), pain in the stomach and belly, dyspepsia (indigestion), nausea, constipation, diarrhoea, vomiting, pruritus (itching), rash, ecchymosis (bruising), pain in the arms and legs, decreased kidney function, fever, peripheral oedema (swelling, especially of the ankles and feet), decreased general strength and energy, increased levels of some liver enzymes in the blood and oozing of blood or fluid from a surgical wound.

For the full list of all side effects reported with Xarelto, see the package leaflet.

Xarelto must not be used in patients who are bleeding or in patients who have a liver disease or a condition that increases the risk of bleeding. Xarelto must not be used together with any other anticoagulant medicines, except in specific circumstances. Xarelto must not be used in women who are pregnant or breast-feeding. For the full list of restrictions, see the package leaflet.

The European Medicines Agency decided that Xarelto’s benefits are greater than its risks and recommended that it be given marketing authorisation.

The company that markets Xarelto will provide an educational pack for doctors who prescribe Xarelto for patients with atrial fibrillation, DVT, pulmonary embolism, or who have had acute coronary syndrome, containing important safety information including on the risk of bleeding during treatment with Xarelto and how to manage this risk. Prescribers will also receive a patient alert card to give to patients receiving Xarelto containing key safety reminders for patients.

The company will also gather more data on the safety of Xarelto when used in patients who have had acute coronary syndrome.

Recommendations and precautions to be followed by healthcare professionals and patients for the safe and effective use of Xarelto have also been included in the summary of product characteristics and the package leaflet.

The European Commission granted a marketing authorisation valid throughout the European Union for Xarelto on 30 September 2008.

For more information about treatment with Xarelto, read the package leaflet (also part of the EPAR) or contact your doctor or pharmacist.