Should I stop Rivaroxaban now and start Innohep (Tinzaparin) tomorrow for a patient with impaired renal function undergoing PCN on Monday?

Management of Rivaroxaban Before Percutaneous Nephrostomy in a Patient with Impaired Renal Function

You should stop rivaroxaban now (Friday) and start Innohep (tinzaparin) 4500 IU tomorrow (Saturday) as bridging therapy before the PCN procedure on Monday, given the patient's severely impaired renal function (GFR 18 mL/min) and high bleeding risk procedure. 1

Patient Assessment

• 75-year-old patient with:
  • Severe renal impairment (GFR 18 mL/min, creatinine 279)
  • Currently on rivaroxaban 2.5 mg BID + aspirin 100 mg
  • Recent cystectomy with stoma (2 months ago)
  • Compensated metabolic acidosis
  • Scheduled for bilateral PCN on Monday (high bleeding risk procedure)
  • Already took morning dose of rivaroxaban today (Friday)

Management Algorithm

Step 1: Stop Rivaroxaban Immediately

• With severe renal impairment (GFR 18 mL/min), rivaroxaban clearance is significantly reduced 2
• Rivaroxaban is 33% renally cleared, and exposure increases by 64% in patients with severe renal impairment 2
• Longer interruption time is required for patients with renal impairment before invasive procedures 1
• For high bleeding risk procedures with CrCl <30 mL/min, rivaroxaban should be stopped at least 3 days before the procedure 1

Step 2: Bridging Anticoagulation

• Start Innohep (tinzaparin) 4500 IU tomorrow (Saturday) 1
• Low molecular weight heparins like tinzaparin are preferred over unfractionated heparin for bridging in patients with moderate renal dysfunction 1
• Continue tinzaparin until 24 hours before the procedure (Sunday)
• Do not administer tinzaparin on Monday morning before the procedure

Step 3: Post-Procedure Management

• Resume anticoagulation based on bleeding risk assessment after PCN
• For high bleeding risk procedures, wait 48-72 hours post-procedure before resuming rivaroxaban 1
• Consider reduced dose when restarting (rivaroxaban 10 mg once daily) for the first 2-3 days 1
• If immediate post-procedure anticoagulation is needed, consider prophylactic dose of heparin/LMWH starting 6-12 hours after procedure 1

Important Considerations

Renal Function Impact

• The patient's severe renal impairment (GFR 18 mL/min) significantly prolongs rivaroxaban's half-life 2
• Standard discontinuation periods are insufficient for patients with this level of renal dysfunction 3
• Rivaroxaban 2.5 mg BID is typically used for coronary artery disease in combination with aspirin, but requires dose adjustment or alternative agents in severe renal impairment 1

Bleeding Risk

• PCN is considered a high bleeding risk procedure
• The patient's advanced age (75 years) and severe renal impairment further increase bleeding risk 1
• The recent cystectomy (2 months ago) may also contribute to increased bleeding risk

Common Pitfalls to Avoid

1. Inadequate discontinuation time: Failing to account for severely impaired renal function when determining rivaroxaban discontinuation timing 3
2. Immediate post-procedure anticoagulant resumption: Resuming full-dose anticoagulation too soon after a high bleeding risk procedure 1
3. Overlooking drug interactions: Medications affecting renal function can further impair rivaroxaban clearance 3
4. Ignoring bridging need: In patients with high thrombotic risk, bridging with LMWH is appropriate 1

By following this approach, you can minimize bleeding risk while providing necessary anticoagulation coverage for this high-risk patient undergoing PCN.