Is it safe to start Innohep (tinzaparin) tomorrow afternoon and stop rivaroxaban (Xarelto) immediately, with the last dose of Innohep given on Sunday, before a procedure on Monday?

Perioperative Anticoagulation Management: Rivaroxaban to Innohep Transition

You should stop rivaroxaban today after taking the pill and start Innohep 4500 units tomorrow afternoon, continuing until Sunday before your Monday operation. 1

Rationale for Transition from Rivaroxaban to LMWH

The management of anticoagulation during the perioperative period requires careful timing to minimize both bleeding and thrombotic risks. This transition plan is based on established guidelines for perioperative management of direct oral anticoagulants (DOACs).

Stopping Rivaroxaban

• Rivaroxaban has a half-life of 8-9 hours 1
• For surgical procedures, rivaroxaban should be stopped at least 24 hours before the procedure to reduce bleeding risk 2
• For higher bleeding risk procedures, stopping 2-3 days before surgery is recommended 1

Starting Innohep (Tinzaparin)

• Innohep is a low molecular weight heparin (LMWH) that is effective for thromboprophylaxis 3
• When transitioning from rivaroxaban to another anticoagulant, the new anticoagulant should be started at the time the next rivaroxaban dose would have been taken 2
• Starting Innohep tomorrow afternoon provides appropriate coverage after rivaroxaban's effect begins to wane

Timing Considerations

Pre-operative Schedule:

• Today: Take final rivaroxaban dose
• Tomorrow afternoon: Begin Innohep 4500 units
• Continue Innohep daily until Sunday
• Monday: Procedure with no anticoagulation on day of surgery

This schedule allows:

1. Adequate clearance of rivaroxaban before surgery (>48 hours)
2. Continued thromboprophylaxis with Innohep during the high-risk pre-operative period
3. Appropriate timing for Innohep discontinuation before surgery

Important Considerations

Bleeding Risk

• Innohep has a shorter half-life than rivaroxaban, making it more suitable for perioperative bridging 3
• The last dose of Innohep on Sunday provides sufficient time for its anticoagulant effect to diminish before Monday's procedure

Thrombotic Risk

• Avoiding a gap in anticoagulation reduces the risk of thrombotic events during the perioperative period
• The transition from rivaroxaban to LMWH is a recognized approach for perioperative management 1

Post-Operative Considerations

After your procedure on Monday, resumption of anticoagulation should be based on:

• The bleeding risk of the procedure
• Adequacy of hemostasis achieved
• Your individual thrombotic risk

For most procedures, rivaroxaban can be resumed:

• 24 hours after surgery for low bleeding risk procedures
• 48-72 hours after surgery for high bleeding risk procedures 1

Conclusion

This approach of stopping rivaroxaban today, starting Innohep tomorrow afternoon, and continuing until Sunday provides appropriate anticoagulation coverage while minimizing perioperative bleeding risk for your Monday procedure.