NAPLEX Question of the Week: Coagulation Counseling

This week's question involves knowing appropriate counseling for a widely used anticoagulant.
NAPLEX Question of the Week: Coagulation Counseling

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FS is a 29-year-old female who comes into the pharmacy with a prescription for Xarelto after being diagnosed with a deep vein thrombosis (DVT). The patient has no history of kidney disease or kidney injury. Which of the following counseling points are appropriate to give FS regarding Xarelto? Select all that apply. 

A. Take this medication with food.

B. This medication requires parenteral anticoagulation for 5 days prior to Xarelto initiation.

C. Initial dosing for DVT should be 15mg PO BID for 3 weeks.

D. After 3 weeks, this medication’s correct dosing regimen is 15 mg PO daily.

E. Keep this medication in the original bottle while taking.

F. Take each dose with a full glass of water.



Answer with rationale:

The correct answer is A and C.

Rivaroxaban (Xarelto) is a once-daily factor Xa inhibitor when used for atrial fibrillation or maintenance of venous thromboembolism (VTE) which includes deep vein thrombosis and pulmonary embolism. The usual dose for VTE treatment is 15 mg by mouth BID for 21 days with food, followed by 20 mg by mouth daily with food for a total of 3 months if the DVT was provoked by a transient risk factor such as a long car or plane ride, or longer than 3 months if the DVT was unprovoked. Doses of rivaroxaban above 10 mg need to be taken with food for best absorption, making answer choice A correct. Edoxaban, dabigatran, and warfarin all require parenteral coagulation at the initiation of therapy, but apixaban and rivaroxaban do not, making answer choice B incorrect. Although the patient does not have a history of kidney disease or kidney injury, there are no dose adjustments for rivaroxaban in the treatment of VTE, but if creatinine clearance is < 15 ml/min, the use of rivaroxaban should be avoided.  After the 21-day initiation dose of 15mg BID (answer C), the maintenance dose is 20 mg by mouth daily with food, making answer choice D incorrect. Rivaroxaban does not need to be stored in its original container or taken with a full glass of water, making answer choices E and F incorrect. These are both important pearls that go with dabigatran (Pradaxa), as it has to be in its original container to be protected from moisture, and needs a full glass of water to reduce the occurrence of pill esophagitis.

NAPLEX Competency Statements Covered:

2.2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied

3.4 – Drug dosing or dosing adjustments; duration of therapy

3.6 – Drug contraindications, allergies, or precautions

3.7 – Adverse drug effects, toxicology, or overdose


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