How long should Xarelto (rivaroxaban) be held before a colonoscopy?

From the Guidelines

Rivaroxaban (Xarelto) should be held for at least 48 hours before a colonoscopy, as this allows for approximately 5-6 half-lives to pass, minimizing the anticoagulant effect and reducing the risk of procedural bleeding. This recommendation is based on the most recent and highest quality study available, which suggests that withholding DOACs for 2 full days before a surgery/procedure should result in minimal to no residual anticoagulant effect at the time of surgery 1. For patients with normal renal function, a 48-hour hold is generally sufficient, but for those with impaired kidney function (creatinine clearance <30 mL/min), a longer period of 72 hours may be necessary due to delayed drug clearance. After the colonoscopy, Xarelto can usually be resumed 24 hours following the procedure if no significant bleeding occurred and adequate hemostasis was achieved. It's worth noting that the European Heart Rhythm Association practical guide suggests that for minor surgical procedures, oral anticoagulation can be continued, and the procedure can be performed 12-24 hours after the last NOAC intake, with the option to restart 6 hours later 1. However, the American College of Chest Physicians clinical practice guideline provides a more detailed approach to the perioperative management of antithrombotic therapy, emphasizing the importance of considering the pharmacokinetics of each DOAC and the individual patient's renal function 1. In contrast, an earlier study suggested stopping rivaroxaban 2 days before surgery, which corresponds to approximately 4 half-lives expired and a minimal residual anticoagulant effect at surgery 1. Overall, the most recent and highest quality evidence supports holding rivaroxaban for at least 48 hours before a colonoscopy to minimize the risk of bleeding and ensure optimal patient outcomes. Key considerations include:

• Patient renal function: impaired renal function may require a longer hold period
• Type of procedure: colonoscopy is considered a low-to-moderate-bleed-risk procedure
• Individual patient factors: age, comorbidities, and concomitant medications may influence the decision to hold or continue anticoagulation.

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 [see Warnings and Precautions (5. 2)] .

Xarelto should be held for at least 24 hours before a colonoscopy to reduce the risk of bleeding.

From the Research

Holding Xarelto Prior to Colonoscopy

• The decision to hold Xarelto (rivaroxaban) before a colonoscopy depends on various factors, including the patient's individual risk of bleeding and thromboembolic complications 2.
• Direct oral anticoagulants like rivaroxaban have a rapid onset and offset of action, and periprocedural bridging is generally not necessary 2.
• There is no specific guideline on how long to hold Xarelto before a colonoscopy, but the management of anticoagulation during elective and emergency colonoscopy involves weighing the risks of precipitating thromboembolic complications if anticoagulants are stopped against the risk of postpolypectomy bleeding if these agents are continued 2.
• A study on the management of anticoagulants and antiplatelet agents during colonoscopy suggests that the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment 2.
• Another study on the optimal timing of anticoagulation pre- and post-colonoscopy with polypectomy found that the management of anticoagulation after polypectomy varies, and there are no published case series documenting when it is safe to resume these medications after polypectomy 3.

Risks and Considerations

• The risk of postpolypectomy bleeding is increased in patients who interrupt warfarin, and the risk of delayed postpolypectomy bleeding is approximately 2.4% for patients who continue thienopyridines and undergo polypectomy 2.
• A study on colonoscopy in patients requiring anticoagulation found that the risk of hemorrhagic complications increases slightly with hot biopsy or snare procedures, and patients taking warfarin for anticoagulation may safely undergo colonoscopy 4.
• The safety of resuming anticoagulation or antiplatelet agents post-polypectomy was found to be safe and did not significantly affect the post-polypectomy rate of hemorrhage in a retrospective review of patients who underwent colonoscopy with polypectomy while on anticoagulation therapy 3.

Anticoagulant Management

• Anticoagulants remain the primary strategy for the prevention and treatment of thrombosis, and novel oral anticoagulants like rivaroxaban have emerged from clinical development and are expected to replace older agents with their ease of use and more favorable pharmacodynamic profiles 5.
• A case study on the use of low-molecular-weight heparin followed by rivaroxaban for acute occlusive portomesenteric vein thrombosis in a cirrhotic patient treated with multiple endoscopic variceal procedures found that no bleeding episode occurred during anticoagulation therapy 6.