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Rivaroxaban – Evaluating NoVel and Effective AnticoaguLant Action (REVEAL Survey)

Survey Questionnaire Form

Doctor's details

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Doctor Name *

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Doctor Name *

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Age *

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Doctor’s Degree*

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Speciality *

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Speciality*

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Qualification *

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City*

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City*

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Predominant type of practice*

Multi-specialty hospital

Clinic/ nursing home

Government hospital/ medical college

Mixed

Questionnaire

In recent years, have you observed an increase in the number of patients suffering from thromboembolic disorders? *

Yes

Can’t say

Maybe at a regional level

If you agree with the increased incidence of thromboembolic events in recent years, which may be the factors leading to this observed rise? (Can select multiple answers)

Higher index of clinical suspicion

Improved diagnostic imaging methods

Lifestyle and food habits (Old age, immobilization, obesity and smoking)

Possible association of Coronavirus exposure, inflammation and VTE*

All of the above

In your daily practice, how frequently do you prescribe an Anticoagulant? *

10%-<20% of patients

20% - <30% of patients

30% - 50% of patients

>50% of patients

While prescribing an Anticoagulant in your practice, what is your primary desired objective? *

Preventing the risk of clots

Reducing chances of stroke/ heart attack

Both

Any other

Do you find any gender preferences in these conditions (male: female) *

No - 50: 50

Yes, Male 70: Female 50

Yes Female 50: Male 70

No preference evident

Which is the most frequent age group of your patients to receive an Anticoagulant? *

30 to 40 years

40 to 50 years

50 to 60 years

< 60 years

According to you, while selecting an Anticoagulant, which of the following parameters are important? (Can select multiple answers) *

Primary objective of prescribing an anticoagulant (e.g.: prevention of thromboembolism/ prevention of stroke}

Patient history (Previous episodes of stroke/ bleeding, CVDs, Cancer etc.)

Presence of comorbidities (diabetes, hypertension etc.)

Renal impairment/ CKD*

Risk of bleeding/ Gastrointestinal bleeding

Smoking/high alcohol intake

Falls/ Recent injury

Route of administration and dosage

All of the above

Which class of Anticoagulants do you prefer and prescribe the most in your patients? (Can select multiple answers) *

Vitamin K antagonists (Warfarin)

Direct Oral anticoagulants (DOACs* – Rivaroxaban, dabigatran, apixaban)

Low molecular weight heparins

Unfractionated Heparin e. Antiplatelet drugs (Aspirin, clopidogrel)

Have you been prescribing the newer anticoagulants – Non vitamin K antagonist oral anticoagulants (NOACs*)? *

Yes

Occasionally

If you regularly prescribe the NOACs, which ones are preferred by you? (Can select multiple answers)

Not routinely used

Rivaroxaban

Apixaban

Dabigatran

What is the one key feature of NOACs due to which you prefer to prescribe these in your patients? Please specify in brief *

In the treatment and management of post-operative thromboprophylaxis, prevention of stroke in patients with non-valvular atrial fibrillation, which of the DOACs* you prefer to prescribe in your patients? *

Rivaroxaban

Apixaban

Edoxaban

Based on patient history and desired outcome

How has been your clinical experience while prescribing Rivaroxaban in your patients? Please specify in brief *

Can you enlist the most important and essential treatment benefits while using Rivaroxaban? (Can select multiple answers) *

Novel and effective mechanism of action - inhibits both free and clot-bound Factor Xa and prothrombinase activity, thereby prolonging clotting times.

Dose ranges from 2.5 mg twice daily to 20 mg once daily.

Faster time to achieve the effect.

Rapid onset of action

Predictable pharmacokinetics and pharmacodynamics

Fewer documented food and drug interactions

Lack of need for routine INR monitoring

Improved patient satisfaction

In your experience, does Rivaroxaban show better/equal anticoagulant efficacy as compared to Apixaban? *

Yes

Clinically equal

Can’t say

Recently, rivaroxaban has also been approved for secondary prevention after acute coronary syndrome (ACS) or peripheral arterial disease (PAD) as an add-on to clopidogrel and aspirin therapy after stabilization with initial management. Do you think the vascular protection benefit is clinically advantageous for patients with ACS and PAD? *

At therapeutic concentrations of rivaroxaban (173–274 μg L−1), INR* rarely exceeds 1.5 and may even be in the reference range (≤1.2). Do you consider this as an important parameter influencing the bleeding risk in patients on Rivaroxaban? *

Yes

Can’t say

May be

Rivaroxaban is excreted via kidneys to a large extent. When do you recommend dosage modification? *

Creatinine clearance ≤30 mL/minute

Creatinine clearance ≤50 mL/minute

Not required unless ESRD/ Creatinine clearance <30 mL/minute

Have you observed an increased risk of spinal/epidural hematoma during anesthesia in a patient on Rivaroxaban? *

Yes

Not yet seen

How frequently do you observe side effects in your patients on Rivaroxaban? Please specify in brief *

Which are the most reported side effects of Rivaroxaban? (Can select multiple answers) *

Bleeding

Bloody stools

Back and abdominal pain

Coughing up blood

Pin/ Needles in limbs

Difficulty in swallowing

Any of the above

Do you agree that routine coagulation testing is not necessary for Rivaroxaban? *

Yes

If you recommend routine coagulation testing in your patients, please specify which category of patients do you prescribe the testing in.

When do you advise the patient to take Rivaroxaban? *

Post breakfast

Post dinner

Post any meals

In your clinical practice, which is the most prescribed/effective dose for Rivaroxaban for management and treatment of DVT*/PE*? *

10 mg

15 mg

20 mg

After the procedure, Rivaroxaban therapy is restarted at the same dose, following adequate hemostasis. Do you agree? *

Yes

No. It should commence with a lower dose

May vary from patient to patient

Post a procedure, what is you preferred method/dose to re-initiate Rivaroxaban? Please specify in brief *

It is seen that premature discontinuation of Rivaroxaban increases the risk of thrombotic events. Do you agree with this statement? *

Yes

May be

The increased risk of thrombotic events post premature discontinuation of Rivaroxaban is evident in which type of patients? Please specify in brief *

In a case where there is no evident risk of bleeding in a patient, do you prescribe Rivaroxaban in comparison to Apixaban? *

Yes

May be

It has been clinically seen that a lower dose of Rivaroxaban (2.5 mg twice per day) in combination with dual antiplatelet therapy significantly improves ischemic outcome in ACS*, including rates of stent thrombosis. This is unlike apixaban and dabigatran which resulted in unfavorable efficacy and safety profiles. In your patients with ACS*, do you prescribe Rivaroxaban for improved outcomes for this clinical benefit? *

Do you think it is safe to prescribe Rivaroxaban in patients with hepatic impairment? Please give your opinion *

Do you think Obesity as a parameter influences the anticoagulant action of Rivaroxaban? *

Yes

May be in some patients

Do you practice estimating the CHADS2* grading score in your patients to evaluate the risk of stroke secondary to atrial fibrillation? *

Yes

Sometimes

Do you feel that the CHADS2* grading score is useful in estimating the risk? Please give your opinion. Also specify if you use any other score/ tool. *

In your clinical practice, have you observed any detrimental effect on the platelet count of a patient receiving Rivaroxaban? *

Yes

Rivaroxaban shows a 21% relative risk reduction in stroke and systemic embolism as compared to Warfarin. Please specify if you have observed this in your clinical practice *

In which type of patients, do you prefer prescribing Rivaroxaban instead of Warfarin? (Can select multiple answers) *

Elderly patients with heart failure

Patients with co-morbidities like diabetes

Patients with history of stroke/ TIA*

In patients prior to MI*

In patients with PAD*

In the Rocket AF trial, Rivaroxaban showed significantly lower incidence of major bleeding and intracerebral bleeding, especially in elderly patients with diabetes as compared to Warfarin. Do you prefer prescribing Rivaroxaban in such patients and why? *

How do you perceive cardiovascular safety of Rivaroxaban in comparison to other Novel anticoagulants? Please give your opinion *

DOAC use in MHV*s has been halted due to the failure of both dabigatran and apixaban in two major clinical trials. However, Rivaroxaban has shown encouraging clinical outcomes in patients with mechanical prosthetic heart valves. Do you advise the use of Rivaroxaban in these patients? *

Yes, can be used

No. Need more clinical evidence

In patients with renal impairment (Crcl*>30 mL/minute), which would be your preferred drug – Rivaroxaban or Dabigatran or Apixaban? *

Rivaroxaban

Dabigatran

Either, based on patient history

Apixaban

Which would be important parameters of preference while prescribing Rivaroxaban over Dabigatran for stroke prevention in NVAF*? (Can select multiple answers) *

Similar efficacy in stroke prevention in AF*

Better prescription flexibility in renally impaired and MHV* patients

Better patient compliance

Higher convenience (Once daily dosage)

All of the above

Rivaroxaban is one and the only anticoagulant indicated to reduce the risk of heart attack, stroke, or cardiovascular death in patients with CAD and PAD. Please specify your clinical experience *

Do you advise Rivaroxaban in patients with CAD and PAD as an add-on for improved outcomes. *

Yes

Occasionally with Aspirin

In your opinion, which of the following outcomes project Rivaroxaban as an influential add-on in patients with CAD? (Can select multiple answers) *

24% risk reduction in incidence of major cardiovascular events

42% risk reduction in incidence of stroke

22% reduction in cardiovascular mortality

No increased risk of fatal and intracranial bleeding

All of the above

COMPASS study has shown that the reduction in CVE* was evident without increasing the risk of fatal and intracranial bleeding when Rivaroxaban was added to Aspirin. *

Do you predict this as an important factor to address the residual risk and prevent the CVEs*? Please specify in brief

In patients with PAD*, Rivaroxaban has shown significant reduction in the risk of major cardiovascular events and acute limb ischemia along with aspirin. *

Have you observed this in your practice? Please specify in brief

Do you prefer Rivaroxaban in PAD* patients *

Yes. I frequently prescribe Rivaroxaban along with Aspirin

No. I am yet to evaluate this combination Occasionally have prescribed.

What would be the major influential outcomes enhanced by addition of Rivaroxaban to aspirin in PAD* patients? (Can select multiple answers) *

Reduction in MACE*

Reduction in Limb Ischemia (Acute/ Critical)

Reduction in Major amputations

All of the above

Rivaroxaban necessitates no bridge with Heparin or LMWH* for DVT* and PE* treatment indications. Do you consider this as an advantageous parameter in the VTE* management? *

Please specify the reasons

Most of the clinical studies conducted for Rivaroxaban involve high risk patients. Do you consider this as an important feature to simulate real world clinical experience Rivaroxaban? *

Yes

What key points should be highlighted in the promotion of RIVAFLO for managing thromboembolism, CAD* and PAD*? (Subjective question) *