How many days should Xarelto (rivaroxaban) be discontinued before a scheduled dental appointment for local anesthesia in an 82-year-old male?

From the Guidelines

For an 82-year-old male on Xarelto requesting dental clearance for local anesthesia, it is recommended to stop Xarelto 24 hours before the scheduled appointment, considering the patient's renal function is normal. The decision to stop Xarelto before a dental procedure should be based on the patient's individual risk factors for bleeding and thrombotic events. According to the study by 1, for patients on rivaroxaban with normal renal function, the medication should be withheld for 24 hours before the procedure. The study suggests that the shorter biological half-lives of non-vitamin K antagonist oral anticoagulants (NOACs) like rivaroxaban have reduced the duration of needed drug discontinuation compared with vitamin K antagonists (VKAs), with wash-out of anticoagulant effects obtained within 24 to 48 hours in most cases. However, another study by 1 suggests stopping rivaroxaban 2 days before surgery, but this may not be necessary for minor dental procedures. Considering the patient's age and the potential risks associated with stopping anticoagulation, it is generally recommended to continue Xarelto without interruption for minor dental procedures, including those with local anesthesia. If the dental procedure is considered high-risk for bleeding or if the patient has additional bleeding risk factors, a temporary interruption of Xarelto may be considered, and the medication can usually be resumed 24 hours after the procedure if adequate hemostasis is achieved. The dentist should use local hemostatic measures such as pressure, sutures, gelatin sponges, or tranexamic acid mouthwash to control any bleeding during and after the procedure. Some key points to consider include:

• The patient's renal function, as this can affect the half-life of rivaroxaban
• The type of dental procedure, as some may be considered higher risk for bleeding
• The patient's individual risk factors for bleeding and thrombotic events
• The use of local hemostatic measures to control bleeding during and after the procedure.

From the FDA Drug Label

If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding The patient should stop taking XARELTO at least 24 hours before the scheduled dental appointment.

From the Research

Rivaroxaban and Dental Procedures

• Rivaroxaban is a direct oral anticoagulant (DOAC) that requires careful consideration in patients undergoing surgical or interventional procedures, including dental procedures 2.
• The decision to interrupt rivaroxaban therapy before a dental procedure depends on the individual patient's risk of thrombosis and bleeding, as well as the type of procedure being performed 2.

Bleeding Risk and Rivaroxaban Interruption

• In patients with a low bleeding risk, rivaroxaban therapy can be continued or reduced in intensity 2.
• In patients with an intermediate or high bleeding risk, temporary interruption of rivaroxaban therapy may be feasible, depending on the individual patient's risk factors and the planned procedure 2.
• However, there is limited data available on the specific management of rivaroxaban in patients undergoing dental procedures, and the decision to interrupt therapy should be made on a case-by-case basis 3.

Rivaroxaban Pharmacology and Renal Impairment

• Rivaroxaban is primarily metabolized by the liver, but it also undergoes some degree of renal elimination, which can affect its pharmacokinetics in patients with renal impairment 4, 5.
• Patients with renal impairment may require closer monitoring and dose adjustment when taking rivaroxaban, but the drug can still be a viable option for anticoagulation in these patients 4, 5.

Specific Guidance on Rivaroxaban Interruption for Dental Procedures

• Unfortunately, there is no specific guidance available in the provided studies on the exact number of days that rivaroxaban should be stopped before a scheduled dental appointment.
• However, it is generally recommended that patients taking rivaroxaban should have their kidney function assessed prior to and during continued therapy, and that the benefits and risks of interrupting therapy should be carefully assessed and balanced on a case-by-case basis 5.