How long should Xarelto (rivaroxaban) be stopped before hernia repair surgery in a patient with normal renal function?

Timing of Rivaroxaban Discontinuation Before Hernia Repair

For patients with normal renal function, rivaroxaban (Xarelto) should be stopped at least 24 hours before hernia repair surgery, as this is considered a low-to-moderate bleeding risk procedure. 1

Evidence-Based Recommendations for Rivaroxaban Discontinuation

The timing of rivaroxaban discontinuation before surgery depends on two key factors:

1. The bleeding risk associated with the procedure
2. The patient's renal function

For Hernia Repair (Low-to-Moderate Bleeding Risk Procedure):

• Normal renal function (CrCl ≥50 mL/min): Stop rivaroxaban 1 day before surgery (skip 1 dose) 1
• Moderate renal impairment (CrCl 30-50 mL/min): Stop rivaroxaban 2 days before surgery (skip 1 dose) 1
• Severe renal impairment (CrCl 15-29.9 mL/min): Stop rivaroxaban 3 days before surgery (skip 2 doses) 1

Dosing Schedule Based on Administration Time:

For once-daily rivaroxaban regimen with normal renal function:

• Morning intake: Last dose should be on the morning of the day before the procedure 1
• Evening intake: Last dose should be two days before the procedure 1

Resumption of Anticoagulation After Surgery

Rivaroxaban can be resumed after surgery based on the following guidelines:

• Resume at least 6 hours after the end of the procedure if there is no ongoing bleeding 1
• For once-daily regimen with morning intake: Resume the next morning after surgery 1
• For once-daily regimen with evening intake: Resume the evening of the surgery day 1

Important Considerations

• No bridging therapy needed: Preoperative bridging with heparin is not recommended when interrupting rivaroxaban 1
• No routine laboratory monitoring required: There is no need to measure rivaroxaban concentration before the procedure when following the recommended interruption periods 1
• Bleeding risk: An INR >3 increases the risk of postoperative hematoma in hernia repair 2
• Rapid onset of action: Rivaroxaban has a peak effect occurring 1-3 hours after intake, requiring cautious administration after surgery 1

Special Situations

• If the hernia repair involves neuraxial anesthesia (spinal/epidural), consider a longer interruption time of up to 5 days for rivaroxaban in patients with normal renal function 1
• For emergency hernia repair, the FDA label states that rivaroxaban should be stopped at least 24 hours before the procedure to reduce bleeding risk 3

Postoperative Considerations

• If venous thromboprophylaxis is indicated after surgery but rivaroxaban resumption must be delayed due to bleeding risk, consider heparin or fondaparinux starting at least 6 hours after the procedure 1
• Monitor for signs of bleeding after resuming rivaroxaban, particularly at the surgical site

Following these evidence-based guidelines for perioperative management of rivaroxaban will help minimize both bleeding and thrombotic risks during hernia repair surgery.