Do patients on Xarelto (rivaroxaban) require heparin for Deep Vein Thrombosis (DVT) prophylaxis?

Patients on Xarelto Do Not Need Additional Heparin for DVT Prophylaxis

Patients who are already taking Xarelto (rivaroxaban) do not require additional heparin for deep vein thrombosis (DVT) prophylaxis, as Xarelto itself is an effective anticoagulant that provides sufficient prophylaxis against venous thromboembolism (VTE). 1

Mechanism and Indications

Rivaroxaban (Xarelto) is a direct oral factor Xa inhibitor that is approved for multiple indications including:

• VTE prophylaxis after major orthopedic surgery (10 mg once daily)
• Treatment of DVT/PE (15 mg twice daily for 3 weeks, then 20 mg once daily)
• Long-term prevention of recurrent VTE (20 mg once daily)
• Stroke prevention in non-valvular atrial fibrillation (20 mg once daily, or 15 mg once daily if CrCl 30-49 mL/min) 1

Evidence Against Additional Prophylaxis

The French Working Group on Perioperative Hemostasis (GIHP) guidelines explicitly state:

• "There is no need for preoperative heparin bridging (UFH or LMWH) except for very thrombotic high-risk." 1
• "There is no need for biological monitoring when the recommended interruption periods are applied and there is no additional risk of drug accumulation." 1

Adding heparin to a patient already on Xarelto would constitute duplicate anticoagulation therapy, which increases bleeding risk without providing additional thromboprophylactic benefit.

Clinical Effectiveness of Rivaroxaban

Rivaroxaban has been shown to be:

• More effective than enoxaparin (LMWH) for VTE prophylaxis after total hip and knee replacement surgery 2, 3
• Non-inferior to standard therapy (enoxaparin followed by vitamin K antagonist) for treatment of DVT and PE 4
• Associated with a lower risk of symptomatic VTE compared to LMWH in routine practice after hip or knee arthroplasty (0.47% vs. 0.81%) without significant difference in major bleeding 3

Special Considerations

Perioperative Management

If a patient on Xarelto requires surgery:

1. Discontinue Xarelto before procedures with high bleeding risk:

   • 3 days before procedure if CrCl >30 mL/min
   • 4-5 days before procedure if CrCl <30 mL/min or high-risk procedures 1

2. For resumption after surgery:

   • If VTE prophylaxis is indicated immediately post-op (before Xarelto can be safely restarted), heparin or fondaparinux can be administered at least 6 hours after the procedure
   • Resume Xarelto at therapeutic dose 24-72 hours postoperatively when surgical hemostasis is achieved 1
   • If prophylactic LMWH was used temporarily, administer Xarelto 12 hours after the last prophylactic LMWH dose 1

Cautions

• Avoid neuraxial anesthesia/spinal procedures in patients with possible residual Xarelto concentration 1
• Monitor renal function postoperatively as it may affect Xarelto dosing 1
• In patients with early phase DVT/PE who are on higher initial doses of rivaroxaban (15 mg BID), a personalized approach should be discussed by a multidisciplinary team if procedures are necessary 1

Conclusion

Patients already on therapeutic Xarelto do not need additional heparin for DVT prophylaxis. Adding heparin would provide duplicate anticoagulation without additional benefit and would increase bleeding risk. The only exception would be during the perioperative period when Xarelto must be temporarily discontinued and bridging with heparin might be considered for patients at very high thrombotic risk.