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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.

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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].

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Last Update: February 16, 2023.



Rivaroxaban is an oral anticoagulant and direct factor Xa inhibitor which is used in the prevention of stroke and venous embolism in patients with chronic atrial fibrillation, as well as treatment and prevention of deep venous thromboses and pulmonary embolism. Rivaroxaban has been associated with a low rate of serum enzyme elevations during treatment and with rare instances of clinically apparent liver injury with jaundice.


Rivaroxaban (riv" a rox' a ban) is a selective inhibitor of factor Xa, the rate controlling last step in the generation of thrombin, the final intermediate in blood coagulation. Inhibiting thrombin prevents the conversion of fibrinogen to fibrin and subsequent cross linking of fibrin monomers, platelet activation and amplification of coagulation. Rivaroxaban has been shown to be as effective as warfarin in preventing stroke and systemic embolization in patients with atrial fibrillation, and to decrease the risk of deep vein thrombosis and pulmonary embolism in patients undergoing surgery. Rivaroxaban is orally available and provides a reliable anticoagulant effect for which monitoring of INR is not needed. Rivaroxaban was approved for use in the United States in 2011, the first oral factor Xa inhibitor to become available. Current indications are for prevention of stroke and embolism in patients with chronic atrial fibrillation not related to valvular heart disease, as well as prevention and treatment of deep vein thrombosis and pulmonary embolism in patients at high risk. Long term therapy in low doses given twice daily in combination with aspirin has been shown to decrease major cardiovascular events and death in patients with coronary or peripheral artery disease. Rivaroxaban is available in tablets of 2.5, 10, 15 and 20 mg generically and under the brand name Xarelto. The recommended dose in adults is 10 to 20 mg daily or 2.5 mg twice daily depending upon indication and renal function. Rivaroxaban, like other anticoagulants, is associated with an increased risk of adverse bleeding events (5% to 6%) which are considered “major” in ~1%. These bleeding adverse events, however, are no more frequent than with low molecular weight heparins or warfarin. Side effects not directly attributable to the anticoagulant activity of rivaroxaban are not common, but can include nausea, abdominal discomfort, back pain, anorexia, fever, and skin rash. Severe adverse events include major bleeding episodes, epidural or spinal hematoma, and increase in risk of thrombotic events with premature discontinuation.


Chronic therapy with rivaroxaban is associated with moderate ALT elevations (greater than 3 times the upper limit of normal) in 1.5% to 3% of patients, an overall rate which is slightly lower than with low molecular weight heparins and similar to the rates with warfarin. During the large, prelicensure clinical trials of rivaroxaban, several instances of ALT elevations with jaundice occurred, but few details were provided and it was not clear whether the liver injury was clinically apparent. The cases were evidently mild and self-limited, resolving completely once therapy was stopped. Since its licensure and more wide scale use, rivaroxaban has been linked to many instances of acute liver injury with jaundice. The clinical features of these cases varied widely. Most cases had an onset within 1 to 8 weeks of starting rivaroxaban and presented with jaundice, fatigue and a hepatocellular pattern of serum enzyme elevations. In some individuals, a cholestatic or mixed pattern was found. Immunoallergic features and autoimmune markers were atypical but at least one case occurred with skin rash and fever suggestive of DRESS syndrome. One case of acute hepatic necrosis and death attributed to rivaroxaban has been reported, but ischemic hepatitis due to severe heart failure was a more likely cause of the acute liver failure. All other reported cases of rivaroxaban induced liver injury recovered upon stopping rivaroxaban, usually quite promptly, within 2 to 4 weeks. In large health care databases, hospitalization for acute liver injury arises in approximately 1 in 2,200 cases, but whether all cases in these databases represent liver injury from rivaroxaban is uncertain.

Likelihood score: A (well established cause of clinically apparent liver injury).

Mechanism of Injury

The cause of liver injury during rivaroxaban therapy is unknown, but is likely to be idiosyncratic and perhaps immunologic. Rivaroxaban is metabolized in the liver largely by CYP 3A4 and is susceptible to drug-drug interactions; inhibitors of CYP 3A4 (such as clarithromycin and itraconazole) can lead to increased levels, while inducers of CYP 3A4 (such as rifampin and phenytoin) can cause decreased and potential subtherapeutic drug levels.

Outcome and Management

Liver injury attributed to rivaroxaban varies from mild serum ALT elevations to liver injury with jaundice, but is usually mild to moderate in severity and self-limited, resolving within a few weeks of stopping. Convincing examples of acute liver failure, chronic hepatitis or vanishing bile duct syndrome due to rivaroxaban have not been reported in the published literature. Recurrence of liver injury with rechallenge has not been described, but should be expected to occur. There is no evidence or reason to suspect that there is cross sensitivity to hepatic injury among the different anticoagulants even with the other direct factor X inhibitors such as apixaban and edoxaban which appear to have a lower rate of hepatotoxicity.

Drug Class: Antithrombotic Agents, Anticoagulants

Other Drugs in the Subclass, Anticoagulants, Factor Xa Antagonists: Apixaban, Betrixaban, Edoxaban, Fondaparinux



Rivaroxaban – Xarelto®


Antithrombotic Agents


Product labeling at DailyMed, National Library of Medicine, NIH


Rivaroxaban 366789-02-8 C19-H18-Cl-N3-O5-S image 135213418 in the ncbi pubchem database


References updated: 16 February 2023

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    (87 year old man with sepsis, atrial fibrillation, and respiratory failure developed marked elevations in serum aminotransferase levels within hours of receiving a single dose of rivaroxaban [peak values on day 2: bilirubin 2.1 mg/dL, ALT 3963 U/L, AST 9549 U/L, Alk P 122 U/L, creatinine 2.8 mg/dL], with rapid recovery; the injury most likely due to ischemic hepatitis).
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    (Search of Icelandic National Prescription Databases and Health Records identified 3 cases of clinically apparent, acute liver injury in 3 of 3446 [0.1%] patients taking rivaroxaban, but in none of 9101 taking warfarin, 1903 apixaban, 1335 dabigatran or 34 taking edoxaban).
  • Zhao J, Blais JE, Chui CSL, Suh IH, Chen EYH, Seto WK, Mok MT, et al. Association between nonvitamin K antagonist oral anticoagulants or warfarin and liver injury: a cohort study. Am J Gastroenterol. 2020;115:1513–1524. [PubMed: 32467502]
    (Among 13,698 patients with atrial fibrillation started on anticoagulant therapy and followed in the Hong Kong Clinical Database and Reporting system between 2010 and 2016, 513 [2.8%] developed evidence of liver injury and propensity matching indicated that liver injury was less frequent [2.1% vs 3.4%], although more severe with oral anticoagulants than with warfarin).
  • Maura G, Bardou M, Billionnet C, Weill A, Drouin J, Neumann A. Oral anticoagulants and risk of acute liver injury in patients with nonvalvular atrial fibrillation: a propensity-weighted nationwide cohort study. Sci Rep. 2020;10:11624. [PMC free article: PMC7363898] [PubMed: 32669591]
    (Among 434,015 patients with atrial fibrillation started on anticoagulant therapy and followed in the French National Healthcare Database, 218 [0.6%] were subsequently hospitalized for acute liver injury, the rates being similar for those on dabigatran [26 of 51,737 patients], apixaban [29 of 62,503 patients] and rivaroxaban [46 of 99,408 patients]).
  • Zhou J, Leung KSK, Kong D, Lee S, Liu T, Wai AKC, Chang C, et al. Low rates of liver injury in edoxaban users: Evidence from a territory-wide observational cohort study. Clin Cardiol. 2021;44:886–889. [PMC free article: PMC8259145] [PubMed: 33590891]
    (Among 1213 patients with atrial fibrillation started on edoxaban between 2016 and 2020 and followed in the Hong Kong Clinical Database and Reporting System, 19 [1.5%] developed evidence of liver injury, a rate below that previously reported for warfarin [3.7%], apixaban [2.5%], and rivaroxaban [2.1%]).
  • Rao V, Munasinghe A. Acute liver failure after changing oral anticoagulant from apixaban to rivaroxaban. BMJ Case Rep. 2021;14:e240719. [PMC free article: PMC8094353] [PubMed: 33910797]
    (88 year old man with atrial fibrillation was switched from apixaban to rivaroxaban [15 mg daily] after experiencing a transient ischemic attack and developed jaundice 2 weeks later [bilirubin 11.2 mg/dL, ALT 1940 U/L, Alk P 360 U/L] but no hepatic encephalopathy, recovering rapidly upon switching to warfarin).
  • Marrinan A, Shackleton L, Kelly C, Lavin M, Glavey S, Murphy P, Quinn J. Liver injury during rivaroxaban treatment in a patient with AL amyloidosis. Eur J Clin Pharmacol. 2021;77:1073–1076. [PubMed: 33427957]
    (57 year old man with amyloidosis developed asymptomatic elevations in serum enzymes 5 months after starting rivaroxaban for a pulmonary embolus [bilirubin 0.6 mg/dL, ALT 544 rising to 806 U/L while continuing rivaroxaban, Alk P 142 U/L], resolving within 2 months of switching to tinzaparin).
  • Ma J, Chalasani NP, Schwantes-An L, Björnsson ES. Review article: the safety of anticoagulants and antiplatelet agents in patients with cirrhosis. Aliment Pharmacol Ther. 2023;57:52–71. [PubMed: 36373544]
    (Review of the safety of anticoagulant use in patients with cirrhosis mentions that drug induced liver injury is uncommon in patients with preexisting cirrhosis, at least in those with compensated [Child’s Class A] or mildly compensated [Child’s Class B] cirrhosis).


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