Xarelto vs. Warfarin: What Is the Best Blood Thinner for Atrial Fibrillation?

If you need to take an anticoagulant (blood thinner), you know that choosing the best option can be confusing. There are many factors to consider, including cost, side effects, and monitoring blood tests. For a long time, warfarin (Coumadin) was the only option. But newer medications — like Xarelto — have entered the market. Both are effective at preventing clots, and both have their advantages and disadvantages. So which one should you choose? We’ll help you decide.

What is Xarelto?

Xarelto (rivaroxaban) is a blood thinner that prevents or dissolves clots in the heart, lungs, and legs. It works by blocking Factor Xa — a special protein in the blood that plays an important role in the clotting process. 

In 2011 the FDA approved Xarelto. Since then it has been a popular alternative to older blood thinners, like warfarin (Coumadin). Healthcare providers prescribe Xarelto for:

• Blood clots in the legs (deep venous thrombosis)

• Blood clots in the lungs (pulmonary embolism)

• People who are at increased risk of blood clots 

• Stroke prevention in people who have atrial fibrillation

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How do Xarelto and other new anticoagulants compare to warfarin?

Xarelto is part of a new class of medications called “Factor Xa inhibitors.” Warfarin has been around for much longer — the FDA first approved it in 1954. It prevents clots by reducing vitamin K levels in the blood. The body uses vitamin K in a chemical reaction that creates clots. 

Xarelto and other Factor Xa inhibitors are a welcome alternative to warfarin for people who need to take a blood thinner. But Xarelto and warfarin each have their own pluses and minuses. Some of the important points of comparison are:

• Blood levels: It can take several days for warfarin to reach the right level in the blood — the INR level (international normalized ratio). Even after it reaches the right level, a lot of things can make that level go too high or too low. Xarelto, on the other hand, starts working right away. Xarelto also has fewer interactions with food and other medications.

• Monitoring: Because of the day-to-day change in the blood level, warfarin requires frequent blood testing to make sure that it’s at the right level. Xarelto does not require any monitoring.

• Price: Xarelto is usually more expensive than warfarin.

• Other medical conditions: Research shows that warfarin is either safer or more effective for people with severe kidney disease, antiphospholipid syndrome, or mechanical heart valves.

• Bleeding risk: Because warfarin is more challenging to keep at the right dose in the blood, there may be a higher risk of bleeding, clotting, or death.

• Reversibility: If someone is taking a blood thinner and develops life-threatening bleeding, healthcare providers try to quickly reverse the effects of their medication. A combination of vitamin K and a powerful antidote (Prothrombin Complex Concentrate or K-Centra) can often quickly reverse warfarin. This antidote may also help reverse the effects of Xarelto, but there’s not enough evidence yet to know how effective it is.

What are some side effects of Xarelto?

The side effects of Xarelto are similar to the side effects of any blood thinner. The most common side effect is increased the risk of bleeding. This includes anything from a bleeding cut in the skin to a life-threatening bleed in the brain after a bad fall. 

This risk of bleeding increases even more if you take other medications that also thin the blood, including:

• Aspirin

• Clopidogrel (Plavix)

• NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen (Advil, Motrin) and naproxen (Aleve)

• Some antidepressant medications, like SSRIs (selective serotonin reuptake inhibitors) or SNRIs (serotonin norepinephrine reuptake inhibitors)

• Any other blood-thinning medication, such as heparin or warfarin

The risk of bleeding while taking Xarelto also increases in those with liver disease or heavy alcohol consumption.

Xarelto (and warfarin) can also increase the risk of blood clots if you suddenly stop taking it or miss doses. This is due to a rebound effect; the body makes extra clotting factors for up to 180 days after you stop taking the medication.

How to save on Xarelto

There are ways to save on Xarelto, which is only available as a brand-name medication. GoodRx can help you navigate between patient assistance programs and copay savings cards to save money on your prescription.

• Save with patient assistance programs. If you’re uninsured or underinsured, you may be eligible for Xarelto's patient assistance program, which offers the medication free of cost.

• Save with a copay savings card. If you have commercial insurance, you may be eligible to pay as little as $10 for Xarelto using a savings card from the manufacturer.

Is Xarelto a better blood thinner than warfarin?

Xarelto and warfarin are about equally effective at preventing blood clots. But with warfarin, it can be tricky to find the most effective dose. There are a lot of things that can affect warfarin dosing (measured by INR levels in the body). This affects how effective it is at preventing blood clots. 

Things that can make warfarin levels go too high or too low include:

• Food with high levels of vitamin K — like green vegetables — can make warfarin less effective.

• Medications can affect warfarin levels, especially anti-seizure medications, thyroid hormone replacement, and certain antibiotics.

• Herbal teas and supplements can affect your INR level with warfarin.  

• Individual genetics can also affect the way your body processes warfarin. This can make dosing more challenging. 

The choice between Xarelto and warfarin is not simple. The convenience of Xarelto dosing often tips the scale in its favor. But warfarin might still be a good choice for people who are not taking a lot of other medications — and who don’t mind avoiding certain foods or supplements. 

If you’re trying to choose the right blood thinner, talk to your healthcare provider about your questions and concerns. They can help you understand your particular risks and benefits with each one.

Alternatives to Xarelto

There are other Factor Xa inhibitors that are similarly effective as Xarelto. These include: 

• Apixaban (Eliquis)

• Fondaparinux (Arixtra) 

• Dabigatran etexilate (Pradaxa)

All of these have slightly different advantages and disadvantages, depending on the condition they’re treating/preventing and your individual preferences and risks. The costs of these medications vary, but they’re all on the more expensive side, like Xarelto.

Why trust our experts?

Written by:

Valerie Anne Jones, MD

Val Jones, MD, is a physician who is certified by the American Board of Physical Medicine and Rehabilitation (ABPMR).

Edited by:

Katie E. Golden, MD

Katie E. Golden, MD, is a board-certified emergency medicine physician and a medical editor at GoodRx.

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