The People's Perspective on Medicine

Is Aspirin Better Than Xarelto (Rivaroxaban) To Prevent 2nd Stroke?

Anyone who has had a stroke must try very hard to prevent a recurrence. A new study asked the question: is Xarelto better than aspirin or is aspirin better than Xarelto. Learn the surprising answer.

Strokes are nasty business. When a blood clot lodges in a brain artery, it leads to the death of neurons. Depending upon where the damage occurs, patients can have difficulty speaking, moving or balancing. People who have had a stroke due to a clot are more susceptible to another one. That’s why doctors try very hard to prevent repeat blood clots in this highly susceptible population. A new study asked a key question: is aspirin better than Xarelto?

Testing Aspirin Against Xarelto:

Investigators wondered whether the new anticoagulant Xarelto, known generically as rivaroxaban, would be more effective and safer than old-fashioned aspirin. A study published in the New England Journal of Medicine (May 16, 2018) compared a daily dose of 15 mg of Xarelto to 100 mg of aspirin.

The researchers recruited 7,213 volunteers from 31 countries. There were a total of 459 medical centers involved. This was a big and expensive study! It was supposed to last for at least two years. The investigators hypothesized that an anticoagulant like Xarelto would work better than an anti-platelet drug such as aspirin in preventing a second stroke.

Platelets are the sticky part of blood that can clump together to form clots. Aspirin prevents platelets from sticking together. That is why it is sometimes prescribed after someone experiences a TIA (transient ischemic attack) or mini stroke.

Was Aspirin Better Than Xarelto?

There was a lot riding on this clinical trial. The drug companies spent a lot of money trying to answer a huge question: Is Xarelto better than aspirin or is aspirin better than Xarelto? A month’s worth of aspirin can cost under $5.00. Xarelto can run over $500 for a month’s supply.

One might have guessed that Xarelto would have won such a contest hands down. At 100 times the price, we could have hoped for a substantially more effective and safer outcome from Xarelto.

The Big Oops!

This drug trial had to be stopped early. Such a decision was not made lightly. Not only was a lot of money riding on the outcome, lives were at stake. The outcome would influence prescribing patterns for years to come.

The NAVIGATE ESUS trial (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source) was ended prematurely (after 11 months) because people taking Xarelto were at higher risk of major bleeding. In addition, Xarelto was no more effective than aspirin at preventing stroke recurrence.

In Their Own Words, the Authors Stated:

“Major bleeding occurred in 62 patients in the rivaroxaban group (annualized rate, 1.8%), as compared with 23 in the aspirin group (annualized rate, 0.7%). The rate of life-threatening or fatal bleeding was significantly higher in the rivaroxaban group than in the aspirin group (hazard ratio, 2.34), as were the rates of symptomatic intracranial hemorrhage (hazard ratio, 4.02) and clinically relevant nonmajor bleeding (hazard ratio, 1.51).”

Translating that into English, Xarelto was significantly more likely to cause severe or life-threatening bleeding episodes compared to aspirin.

This is not the first time that Xarelto did not live up to expectations. Here is a study that compared aspirin to Xarelto after hip or knee replacement surgery:

The People’s Pharmacy Perspective:

It no doubt came as a great shock to the drug company sponsors of this stroke research to learn that their pricey anticoagulant was neither more effective nor safer than aspirin. We would actually answer the question: is aspirin better than Xarelto? in the affirmative. That’s because this extremely inexpensive OTC drug was less likely to cause hemorrhages. Although it may not have been more effective than Xarelto at preventing another stroke, it clearly won the race on safety.

What are patients to make of this study? First, no one should EVER stop taking Xarelto without very careful medical supervision. In one Xarelto commercial the announcer makes it crystal clear:

“Don’t stop taking Xarelto without talking to your doctor as this may increase risk of stroke.”

There are many health conditions where Xarelto may be an appropriate option. Only the prescribing physician can determine the best course of action. That said, it is important for doctors to familiarize themselves with this new study. If they are trying to prevent a second blood clot to ward off another stroke, they may wish to consider old-fashioned aspirin as a viable option. The study in the New England Journal of Medicine will have an important impact on prescribing patterns for years to come.

Learn more about Xarelto and Eliquis side effects at this link.

Share your own experience with Xarelto in the comment section below.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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Thank you for keeping us informed,it is very useful.

I am on Pradaxa , which is supposed to be in the same family as xarelto, which caused me cutaneous problems. I would like to know if Aspirin could also replace Pradaxa.

Claude C.

We haven’t seen a study that compares aspirin to dabigatran. This would need to be a call by your physician, and he or she may not have enough information to make a decision. There is a little bit of info here:

This test of Xarelto vs. aspirin makes me wonder if aspirin has been tested against warfarin?

If aspirin is as effective as warfarin, this would eliminate the need for going in for expensive blood coagulation testing every six weeks.

I was in hospital after ultrasound showed large femoral blood clot. Started on Coumadin injections and went home knowing how to use. Developed small circular lesions on arms resembling tiny cigarette burns and found it was Coumadin necrosis. Dr. put me on Xarelto.

A year previously, my daughter had a serious internal bleed, having been on Xarelto for a year. Her NEW doctor gave her an article saying the new protocol of the Chest Surgeons organization was 3 to 6 months rather than 6 to 12.

I talked my Dr. into 3 months instead of 6 and gave her a copy of the journal article. Given family history, I am leery about Xarelto use AND Coumadin. I have serious bruising I never had before the “necrosis” episode.

After my heart attack caused by a blood clot due to AFib, diagnosis of angina, and the insertion of 3 stents for RCAD, my doc said I would be taking a BP pill and an aspirin every day for the rest of my life.

Not sure why 3 heart doc’s so far have not even mentioned Warfarin or Xarelto. I did take Effient post-surgery for 9 months, but have been on the BP and aspirin regimen for over 6 years now.

I am a 62 year old female. I think aspirin is a wonder drug. It is made from a natural substance, not a chemical cocktail.

When I experienced Atrial Flutter (this is not AFIB) the doc had me switch from aspirin to Xarelto. I immediately experienced severe bleeding and I think it just about killed me. I at once (after taking Xarelto for about 20 days) switched back to aspirin (I did it w/o the doc’s OK though I think he would have agreed – I just didn’t want to wait).

After my heart was shocked back to normal as a Duke ambulatory patient, I’m doing fine on aspirin (it has been over two years now). All I can advise is to beware of the side effects of new medicines.

I have been on Xarelto for 5 years for DVT which last occurred in 2023. Would aspirin be as good?

I was prescribed for Xarelto but due to the high cost, I requested a less expensive alternate. Now taking 81 mg. of aspirin in concert with 10 mg warfarin 5 times / week and 7.5 the other 2.

Been successful in maintaining cummadin level around 2.3-2.7. Is there a less expensive alternate that I might discuss w/ my Dr.?

I think doctors will never prescribe aspirin over xarelto. Doesn’t matter what the facts show. The ‘real’ medications will always be prescribed.

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