Discontinuation of Rivaroxaban (Xarelto) Before Surgical Procedures
For rivaroxaban (Xarelto), discontinue the medication 1 day before low bleeding risk procedures and 2 days before high bleeding risk procedures, with longer interruption periods (up to 5 days) for very high bleeding risk procedures such as neuraxial anesthesia or intracranial neurosurgery. 1
Timing of Discontinuation Based on Bleeding Risk
Low Bleeding Risk Procedures
- Once-daily morning dosing: Last dose on the morning of the day before procedure
- Once-daily evening dosing: Last dose two days before procedure
- Twice-daily dosing: Last dose on the morning of the day before procedure 1
High Bleeding Risk Procedures
- Standard recommendation: Discontinue 3 days before procedure (when creatinine clearance >30 mL/min) 1
- Updated recommendation: Discontinue 2 days before procedure 1
Very High Bleeding Risk Procedures
- Neuraxial anesthesia/intracranial neurosurgery: Up to 5 days discontinuation 1
- Special consideration: Longer interruption may be needed for patients with renal impairment 1
Special Considerations
Renal Function
- Rivaroxaban has partial renal elimination
- Standard discontinuation times apply when creatinine clearance >30 mL/min
- Consider longer discontinuation periods for patients with impaired renal function 1
No Need for Bridging
- Preoperative bridging with heparin (UFH or LMWH) is not recommended 1
- The rapid offset and onset of action of rivaroxaban makes bridging unnecessary 1
Laboratory Testing
- Routine measurement of rivaroxaban levels before procedures is not necessary 1
- Consider testing only in emergent situations to determine if reversal agents are needed 1, 2
Resumption After Procedure
Low Bleeding Risk Procedures
- Resume at least 6 hours after procedure completion:
- Evening dose if once-daily evening regimen
- Next morning if once-daily morning regimen
- Evening of same day if twice-daily regimen 1
High Bleeding Risk Procedures
- For low-to-moderate bleeding risk: Resume at least 24 hours after procedure 1
- For high bleeding risk: Resume 48-72 hours after procedure 1
- If ongoing bleeding or surgical contraindication exists, delay resumption and consider venous thromboprophylaxis 1
Important Timing Considerations
- Rivaroxaban has rapid onset of action (peak effect 1-3 hours after intake)
- Exercise caution when resuming after procedures with high bleeding risk 1
Official FDA Label Guidance
According to the FDA label, rivaroxaban should be stopped at least 24 hours before procedures to reduce bleeding risk. The decision to delay procedures should weigh bleeding risk against intervention urgency 3
Clinical Pearls and Pitfalls
- Common pitfall: Inadequate discontinuation time before high-risk procedures, especially neuraxial anesthesia
- Avoid: Performing spinal/epidural anesthesia or deep-block techniques with insufficient discontinuation time 1
- Caution: Resuming too early after high bleeding risk procedures can lead to significant bleeding complications
- Remember: No need for heparin bridging in most cases, which differs from traditional VKA management 1
This standardized approach to perioperative rivaroxaban management has been associated with low rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) 2.