Xarelto vs. Eliquis: Which is Better?

Introduction

Xarelto (rivaroxaban) and Eliquis (apixaban) are anticoagulant medications used to prevent blood clots in people who are at risk of developing serious conditions such as pulmonary embolism (PE) or deep vein thrombosis (DVT).

There are different causes and risk factors associated with the diseases, and most have to do with external health factors that result in the formation of blood clots. Approximately 600,000 people (about half the population of Hawaii) in the United States are affected by DVT and PE every year, with more than 100,000 Americans dying and 33% suffering from long-term complications.

Previously, warfarin was used as an anticoagulant to prevent blood clots, but it required regular testing to ensure the correct dosage. Recently, the FDA approved new treatment methods called direct oral anticoagulants to improve the mode of treatment.

Xarelto and Eliquis are among the most effective treatment methods for blood clots. While both drugs are effective, they have differences in their pharmacology, dosing, and potential side effects that may make one medication more appropriate for certain patients than the other.

About Xarelto and Eliquis

Xarelto (rivaroxaban) and Eliquis (apixaban) are DOACs targeting different blood clotting factors. These drugs belong to a class of medications called direct oral anticoagulants (DOACs), which inhibit the activity of clotting factors in the blood, making blood less likely to clot. Xarelto and Eliquis were first approved for blood clot treatment in 2012 and 2011, respectively.

What is Xarelto?

Xarelto (rivaroxaban) is an anticoagulant medication used to prevent blood clots in people at risk of developing conditions related to excessive blood clot formation. The brand name medication is available in liquid suspension and tablet form.

What Conditions Is Xarelto Approved to Treat?

Xarelto is a brand-name medication that is FDA-approved for different medical conditions. Xarelto is the first treatment choice for people at risk of developing blood clots and patients suffering from non-valvular atrial fibrillation.

Moreover, Xarelto is used to treat DVT and PE and prevent the recurring of the two conditions, especially in people who have recently undergone surgery. Additionally, Xarelto is prescribed to hospitalized patients that have been stuck in bed, which increases the risk of developing blood clots.

Xarelto is also approved to prevent blood clots in children two years old or above who suffer from congenital heart disease. Doctors can also prescribe the medication for people at risk of serious cardiovascular problems.

Xarelto is available in several doses, and the appropriate dose will depend on the patient's age, weight, and other factors. Patients should inform their healthcare provider of all medications they are taking before starting Xarelto, as Xarelto may interact and produce antagonistic effects with other medications, such as antiplatelet agents and nonsteroidal anti-inflammatory drugs (NSAIDs).

How Does Xarelto Work to Prevent Blood Clots?

Xarelto is an anticoagulant that lowers the chances of blood clots by inhibiting the activity of "Factor Xa(10a),"; an enzyme involved in the clotting process. Factor Xa is an activated form of the Factor X enzyme, hence the "a" in "Xa."

The activated Factor X binds to its cofactor, Factor VII, activating the complex thrombin. The thrombin then converts the dissolved fibrinogen (a protein) into long threads, which then causes the formation of a thrombus (blood clot).

By inhibiting Factor Xa, Xarelto helps prevent blood clots in the veins and arteries. Xarelto is taken orally and is rapidly absorbed by the body, with peak concentrations reached within two to four hours after administration and inhibition of factor Xa occurring after three hours.

By decreasing the chances of the development of blood clots, Xarelto can prevent the onset of DVT and PE, which are directly related to the development of blood clots in the blood vessels of the leg, pelvis, or arm.

Unlike traditional anticoagulants such as warfarin, which require frequent monitoring and dose adjustments, Xarelto does not require routine blood tests to monitor its effectiveness. However, like all anticoagulants, Xarelto increases the risk of bleeding, including gastrointestinal bleeding and hemorrhagic stroke.

Xarelto works by inhibiting Factor Xa, inhibiting its binding to the cofactor and halting the entire process, resulting in an inability of the body to activate thrombin and concurrently produce thrombus.

What is Eliquis?

Eliquis (apixaban) is an anticoagulant medication similar to Xarelto and is used to prevent blood clots. Like Xarelto, Eliquis works by inhibiting the activity of clotting factors in the blood, reducing the chances of blood clot development.

What conditions is Eliquis approved to treat?

Eliquis is approved by the FDA for several medical conditions related to blood clot formation, including the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation, the treatment of DVT and pulmonary embolism (PE), and the prevention of recurrent DVT and PE.

Moreover, Eliquis is a popular choice among doctors to lower the risk of blood clot formation and stroke, especially after serious surgery.

How does Eliquis work?

Eliquis is a highly selective Factor Xa inhibitor which works by inhibiting the activity of both Factor Xa and thrombin; enzymes involved in the clotting process. Eliquis helps prevent blood clots from forming in the veins and arteries by inhibiting these clotting factors.

Although Eliquis does not directly affect platelet aggregation, it can target Factor Xa in the liver and decrease the generation and development of thrombus by inhibiting the activation of the protein thrombin.

Eliquis is available in several doses, and the appropriate dose will depend on the patient's age, weight, and other factors. According to research, the activity and efficacy of Eliquis depend on the dosage, with the half maximal inhibitory concentration; the minimum concentration required to inhibit the production of blood clots, being 329 nM.

Eliquis is taken orally and is rapidly absorbed by the body, with peak concentrations reached within one to three hours after administration. Like Xarelto, Eliquis does not require routine blood tests to monitor its effectiveness.

By decreasing the chances of the development of blood clots, Eliquis can prevent the risk of DVT and PE, which are directly related to the development of blood clots in the blood vessels of the leg, pelvis, or arm.

Effectiveness

How Effective are Xarelto and Eliquis in Treating Blood Clots?

Xarelto and Eliquis are the first-choice treatments for preventing DVT and PE. Moreover, these medications belong to the class DOACS, the first-choice medication for blood clot prevention in patients with nonvalvular atrial fibrillation.

However, there are exceptions when choosing one drug over the other. One research suggests that while Xarelto and Eliquis are similarly effective in treating acute venous thromboembolism (VTE), Eliquis is safer as patients that receive Xarelto experience more bleeding.

Another research studied the safety and efficacy of both medications compared to other anticoagulants, Pradaxa, and warfarin, concluding that Eliquis showed better results.

However, the studies do not give enough insights to conclusively dictate whether one medicine is more effective. Similarly, the choice of medication can depend on the patient's demographics, health, and medical history.

Dosage Information

How is Xarelto Administered for Blood Clot Treatment

Xarelto is a Direct Oral Coagulant, administered orally as a tablet or liquid suspension only for children. Xarelto is available in different dosages:

2.5 milligrams (mg)
10 mg
15 mg
20 mg

Adult patients unable to swallow whole tablets can crush and mix the medication in applesauce for oral administration. The administration should then be followed by food.

Xarelto can also be administered via nasogastric tube (NG) or gastric feeding tube by crushing the tablets and mixing them in 50 mL water.

However, if crushed and mixed with applesauce or water, Xarelto tablets are only stable for up to four hours.

How is Eliquis Administered for Blood Clots?

Eliquis is a Direct Oral Coagulant that is administered orally as a tablet. Xarelto is available in different dosages:

2.5 mg
5 mg
10 mg

Adults unable to swallow Eliquis tablets whole can crush the tablets and mix them in 60 mL water, apple juice, applesauce, or 5% dextrose in water (D5W).

The 60 mL water or D5W mixture can be administered via the nasogastric tube. Similar to Xarelto, the crushed tablets remain stable for around four hours.

Side Effects

What are the Most Common Side Effects of Xarelto?

Some of the most common side effects of Xarelto may include the following:

Back pain
Stomachache
Dizziness
Fatigue
Nosebleeds
Cramps
Insomnia

Although patients might not suffer all side effects, they could suffer from some. You can find more information on Xarelto's side effects on the FDA website.

Are There Any Potential Serious Side Effects of Xarelto?

If you experience any of the following side effects, seek medical help immediately:

Increased bleeding, which could cause excessive blood loss.
Mental health effects such as depression
Increased risk of blood clot development due to incomplete dosage or improper use
Risk of epidural or spinal hematoma if administered after a spinal puncture.
Increased risk of bleeding in acutely ill patients, such as those with a pulmonary or active cancer history.

What are the Most Common Side Effects of Eliquis?

Some of the most common side effects of Eliquis may include:

Low blood cell levels (anemia)
Bruising and bleeding
Nausea
Allergic reaction

However, the onset of side effects depends widely on the patient's health and demographics. You can find more information on Xarelto's side effects on the FDA website.

Are There Any Potential Serious Side Effects of Eliquis?

If you experience any of the following side effects, seek medical help immediately:

Increased bleeding, which could cause excessive blood loss.
Increased risk of blood clot development due to incomplete dosage or improper use
Risk of epidural or spinal hematoma if administered after a spinal puncture.
Increased risk of bleeding in acutely ill patients, such as those with a history of pulmonary hemorrhage or active cancer.

Contraindications and Interactions

Contraindications and Important Interactions of Xarelto and Eliquis

Contraindications

Xarelto

Patients suffering from active pathological bleeding: bleeding at a fatal level

Patients suffering from severe hypersensitivity reactions could cause serious allergic reactions such as anaphylactic shock.

Eliquis

Patients suffering from active pathological bleeding: bleeding at a fatal level

Patients with severe hypersensitivity reactions could cause allergic reactions such as anaphylactic shock.

Drug/Medication Interactions

Xarelto

If replaced with warfarin, it could cause an increased rate of stroke.

If used with drugs that impair hemostasis, such as aspirin, platelet inhibitors, antiplatelet therapy, fibrinolytic therapy, and NSAIDs, it could lead to an increased risk of bleeding.

Interacts with certain antifungal drugs such as ketoconazole and itraconazole and may increase the risk of side effects.

Interacts with ritonavir which may increase the risk of side effects such as excessive bleeding.

Rifampin and antiepileptic drugs such as carbamazepine and phenytoin can decrease the efficacy of Xarelto.

Eliquis

If replaced with warfarin, it could cause an increased rate of stroke.

If used with drugs that impair hemostasis, such as aspirin, platelet inhibitors, antiplatelet therapy, fibrinolytic therapy, and NSAIDs, it could lead to an increased risk of bleeding.

Interaction with rifampin and certain antiepileptic drugs, such as carbamazepine and phenytoin, can decrease efficacy.

Interactions with antifungal drugs such as ketoconazole and itraconazole can increase the risk of side effects.

Interaction with ritonavir and methyltestosterone can increase the risk of side effects.

Food/Beverage/Supplement Interactions

Xarelto

Using Xarelto with grapefruit could increase the risk of side effects, especially bleeding.

St. John’s wort (an herb) may lower the efficacy of Xarelto by decreasing absorption.

Consult your doctor or health provider before taking Xarelto if you take any supplements or vitamins.

Eliquis

Interaction with grapefruit could increase the risk of side effects, especially bleeding and hemorrhage.

Continuous use of St. John’s wort (an herb) may lower the efficacy of Eliquis by decreasing its availability in the body.

Consult your doctor or health provider before taking Xarelto if you take any supplements or vitamins.

Cost Comparison

How Much do Xarelto and Eliquis Cost?

The total cost of Xarelto and Eliquis depends on the patient's treatment plan. Xarelto and Eliquis are brand-named drugs and not available in generic forms. Therefore, there is no set price for the two medications.

The popularity of Xarelto and Eliquis

As of 2022, more than eight million Americans have a prescription for Xarelto and more than 13 million for Eliquis. 76% of Xarelto prescriptions were for the 20 mg tablet, and 84% of Eliquis prescriptions were for the 5.0 mg tablet.

Conclusion

Takeaway

Xarelto and Eliquis are effective anticoagulant medications that inhibit clotting factors in the blood to reduce the chances of blood clots. While they have differences in their pharmacology, dosing, and potential side effects, both drugs are effective in preventing blood clots in high-risk patients. Patients should work with their healthcare provider to determine which medication suits their needs.