All three are PBS-listed, streamlined-authority, GP-prescribable alternatives to warfarin for non-valvular AF and VTE, with no routine INR monitoring. Choice depends on renal function, age/bleeding risk and interacting medicines — confirm the current PBS listing at pbs.gov.au.
1Eligibility — who qualifies
✓NVAF — Non-valvular atrial fibrillation with an elevated stroke risk (CHA₂DS₂-VASc 1 or more), per current PBS criteria.
✓VTE — Treatment of confirmed DVT/PE, and extended prevention after the initial course where listed.
✓Renal basis — Assessed by Cockcroft–Gault creatinine clearance, not eGFR — recalculate, don't rely on a pathology eGFR.
2Which agent — practical comparison
| Agent | Mechanism & renal handling | Often preferred for |
|---|
| Apixaban | Factor Xa inhibitor, twice daily; ~27% renal clearance | Renal impairment, older age, GI-bleed-prone |
| Rivaroxaban | Factor Xa inhibitor, once daily; ~33% renal clearance | Once-daily preference; take with food |
| Dabigatran | Direct thrombin inhibitor, twice daily; ~80% renal clearance | Pre-op reversibility; normal renal function |
Verify at PBS — Doses, renal cut-offs and PBS criteria differ between agents and change — confirm current detail in the AMH, product information, and pbs.gov.au before prescribing.
3Practical prescribing & interactions
- Rivaroxaban (15–20 mg doses): take with food. Apixaban and dabigatran need no food.
- Dabigatran capsules: swallow whole — don't open or repackage (moisture-sensitive).
- Switching anticoagulants follows an agent-specific overlap protocol — check the product information.
- Strong CYP3A4/P-gp inhibitors or inducers (e.g. rifampicin, ketoconazole) — avoid combining.
- Other anticoagulants, antiplatelets and regular NSAIDs add bleeding risk — review at every script.
- Dabigatran with verapamil/amiodarone: a dose adjustment may be advised.
Safety
- Bleeding: minor — delay/reassess; major — stop & supportive care; life-threatening — reverse & refer.
- Andexanet alfa (Andexxa) is no longer TGA-registered (lapsed May 2026) — Prothrombinex (4-factor PCC) is now the mainstay Xa-inhibitor reversal. Idarucizumab remains dabigatran-specific.
Check / exclude
- Mechanical heart valve, moderate–severe mitral stenosis, or antiphospholipid syndrome — use warfarin instead.
- Confirm renal function by Cockcroft–Gault before dosing; re-check at least annually.
- Confirm the current PBS authority requirement before prescribing.
CV-04 v1.0 · Reviewed Jun 2026 · Review Dec 2026
For health-professional use. Comparison adapted from product information, the AMH, and TGA safety updates. Confirm exact doses, renal cut-offs and PBS criteria at pbs.gov.au.
