Why does the cardiologist require Xarelto (rivaroxaban) to be washed out before initiating a heparin drip?

From the Guidelines

When a patient is on Xarelto (rivaroxaban) and the cardiologist mentions it needs to be "washed out" before starting a heparin drip, they are referring to allowing time for the Xarelto to clear from the patient's system, typically waiting at least 24 hours after the last dose of Xarelto before initiating a heparin infusion in most patients with normal renal function, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. This is important because Xarelto is an anticoagulant that directly inhibits Factor Xa and has a half-life of 5-9 hours in most patients, as described in the study on venous thromboembolic disease 1. Overlapping Xarelto with a heparin drip would create excessive anticoagulation and significantly increase bleeding risk. The waiting period may need to be longer (up to 48 hours) in elderly patients or those with impaired kidney function since Xarelto is partially eliminated through the kidneys, as noted in the 2024 WSES guidelines on the management of trauma in elderly and frail patients 1. The washout period ensures that the anticoagulant effects of Xarelto have sufficiently diminished before introducing another anticoagulant, thereby reducing the risk of dangerous bleeding complications that could occur with simultaneous use of two potent blood thinners. Some key points to consider include:

• The half-life of rivaroxaban and its elimination through the kidneys, which can affect the duration of the washout period 1
• The increased risk of bleeding with concurrent use of anticoagulants, as discussed in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1
• The importance of monitoring renal function and adjusting the washout period accordingly, as recommended in the 2024 WSES guidelines on the management of trauma in elderly and frail patients 1
• The need for careful consideration of the timing of anticoagulant initiation and the potential for bleeding complications, as noted in the study on the management of patients with atrial fibrillation 1.

From the FDA Drug Label

Switching from XARELTO to Anticoagulants other than Warfarin - For adult and pediatric patients currently taking XARELTO and transitioning to an anticoagulant with rapid onset, discontinue XARELTO and give the first dose of the other anticoagulant (oral or parenteral) at the time that the next XARELTO dose would have been taken For unfractionated heparin being administered by continuous infusion, stop the infusion and start XARELTO at the same time.

The cardiologist requires Xarelto (rivaroxaban) to be washed out before initiating a heparin drip because there is no direct information in the label that supports the practice of washing out Xarelto before starting heparin. However, the label does provide guidance on switching from XARELTO to other anticoagulants, including unfractionated heparin.

• The label advises to discontinue XARELTO and start the other anticoagulant at the time the next XARELTO dose would have been taken.
• It does not explicitly state that XARELTO needs to be "washed out" before starting heparin, but rather that it should be discontinued before starting the new anticoagulant.
• A conservative approach would be to follow the label's guidance and discontinue XARELTO before starting heparin, but the exact timing and necessity of "washing out" XARELTO is not clearly stated 2.

From the Research

Background on Anticoagulant Therapy

The management of anticoagulant therapy, including the use of Xarelto (rivaroxaban), is crucial in patients undergoing medical procedures to balance the risk of thromboembolic events and bleeding complications.

Rationale for Washing Out Xarelto Before Heparin Drip

• The cardiologist requires Xarelto to be washed out before initiating a heparin drip due to the increased risk of bleeding when both medications are used together 3, 4.
• Xarelto is a novel oral anticoagulant (NOAC) with a specific pharmacokinetic profile, and its interruption before procedures is recommended based on the patient's renal function and individual bleeding risks 5.
• The recommended preoperative interruption of Xarelto is 24-72 hours, depending on the patient's renal function and surgery-related bleeding risks 5.
• Bridging with low molecular weight heparin (LMWH) is generally not recommended due to an increased bleeding risk, but it may be considered in cases of high thromboembolic risk 4, 5.

Considerations for Perioperative Anticoagulation Management

• The decision to discontinue anticoagulant therapy before a procedure should be based on the individual patient's risk of thrombosis and bleeding, as well as the type of procedure being performed 6, 7.
• For patients on Xarelto, the medication can be re-initiated 6-8 hours after the intervention, or after 24-72 hours in cases of more extensive interventions or increased bleeding risk 5.
• In emergency situations where Xarelto has not been adequately washed out, preparations should be made for potential bleeding management, including the use of prothrombin concentrate (PCC) 5.