FPIN's Clinical Inquiries

Rivaroxaban vs. Warfarin for Treatment of DVT and PE


Am Fam Physician. 2017 Oct 15;96(8):532-533.

Clinical Question

Is rivaroxaban (Xarelto) as effective as vitamin K antagonists for the treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE)?

Evidence-Based Answer

Rivaroxaban, along with the other factor Xa inhibitors, is as effective as or better in the short term (three months) than warfarin (Coumadin) for preventing recurrent DVT, nonfatal PE, and fatal PE, with no differences in mortality or bleeding events. (Strength of Recommendation: A, based on consistent, high-quality meta-analyses of moderate- to high-quality randomized controlled trials [RCTs] with patient-oriented outcomes.)

Evidence Summary

A 2015 Cochrane meta-analysis of 11 RCTs (N = 27,945) compared direct thrombin inhibitors, factor Xa inhibitors (rivaroxaban, apixaban [Eliquis], and edoxaban [Savaysa]), and standard anticoagulants (unfractionated heparin, low-molecular-weight heparin, and vitamin K antagonists such as warfarin) in the treatment of venous thromboembolism (VTE) and PE.1 Eight of the RCTs (N = 16,356) compared factor Xa inhibitors with standard anticoagulants; four (N = 9,428) compared rivaroxaban with standard anticoagulants (international normalized ratio goal of 2 to 3). Primary outcomes included recurrent VTE, recurrent DVT, and fatal and nonfatal PE. After three months, there was a significant trend in favor of factor Xa inhibitors compared with warfarin for the prevention of recurrent VTE (five trials, three with rivaroxaban; N = 5,001; odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.48 to 0.99) and recurrent DVT (four trials, two with rivaroxaban; N = 4,917; OR = 0.51; 95% CI, 0.31 to 0.84). When treatment was extended beyond three months, there were no significant differences in rates of recurrent VTE (three trials, one with rivaroxaban; N = 11,355; OR = 0.97; 95% CI, 0.78 to 1.22) or recurrent DVT (three trials, one with rivaroxaban; N = 11,355; OR = 0.87; 95% CI, 0.63 to 1.20) compared with warfarin. Overall, there was a significant decrease in rates of recurrent VTE with factor

Address correspondence to Corey Lyon, DO, at corey.lyon@ucdenver.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

Copyright Family Physicians Inquiries Network. Used with permission.


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1. Robertson L, Kesteven P, McCaslin JE. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis. Cochrane Database Syst Rev. 2015;(6):CD010956....

2. Robertson L, Kesteven P, McCaslin JE. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of pulmonary embolism. Cochrane Database Syst Rev. 2015;(12):CD010957.

3. Cohen AT, Hamilton M, Bird A, et al. Comparison of the non-VKA oral anticoagulants apixaban, dabigatran, and rivaroxaban in the extended treatment and prevention of venous thromboembolism: systematic review and network meta-analysis [published correction appears in PLoS One. 2016;11(9):e0163386]. PLoS One. 2016;11(8):e0160064.

4. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315–352.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.



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