When to stop Xarelto (rivaroxaban) and is bridging necessary for a high-risk thromboembolism patient with impaired renal function (GFR 48 ml/min) undergoing a face lift?

Perioperative Management of Rivaroxaban for Face Lift in High-Risk Thromboembolism Patient with Impaired Renal Function

For a high-risk thromboembolism patient with GFR 48 ml/min on rivaroxaban undergoing a face lift, rivaroxaban should be stopped 2 days before surgery (skip 1 dose) and resumed 48-72 hours after surgery without bridging therapy.

Preoperative Management

Timing of Rivaroxaban Discontinuation

• Face lift surgery is considered a procedure with moderate-to-high bleeding risk due to the extensive vascularity of the face
• For patients with moderate renal impairment (CrCl 30-50 ml/min), rivaroxaban should be stopped 2 days before surgery 1, 2
• With GFR 48 ml/min, the patient falls into this category requiring a 2-day discontinuation period

Specific Timing Based on Dosing Schedule

• For once-daily rivaroxaban regimen with morning intake: Last dose should be taken on the morning 2 days before the procedure
• For once-daily rivaroxaban regimen with evening intake: Last dose should be taken 3 days before the procedure 1, 2

No Need for Bridging Therapy

• Despite the patient being high-risk for thromboembolism, bridging with heparin is generally not recommended when interrupting rivaroxaban 1
• Bridging is only considered in very specific cases such as recent (<3 months) history of pulmonary embolism or deep venous thrombosis 1
• Rivaroxaban has a shorter half-life compared to warfarin, making the window of subtherapeutic anticoagulation shorter 1

Postoperative Management

Timing of Rivaroxaban Resumption

• For high bleeding risk procedures like face lift surgery, rivaroxaban should be resumed 2-3 days after surgery (48-72 hours postoperative) 1
• This allows sufficient time for wound healing and hemostasis to occur
• The FDA label for Xarelto states that it should be restarted "as soon as adequate hemostasis has been established" 3

Dosing Considerations for Resumption

• For patients at high risk for thromboembolism, consider administering a reduced dose initially:
  • Option 1: Resume with 10 mg once daily for the first 2 days, then increase to regular dose 1
  • Option 2: Resume with full dose but only after confirming adequate hemostasis 1

Special Considerations

Monitoring

• No routine laboratory monitoring of rivaroxaban concentration is required when following the recommended interruption periods 1
• If there are concerns about residual anticoagulant effect, specific anti-Xa assays can be considered, though not routinely recommended

Potential Complications

• Early resumption increases bleeding risk, particularly in the highly vascular face area
• Delayed resumption increases thromboembolism risk in this high-risk patient
• If postoperative bleeding occurs, consider delaying resumption further and implementing mechanical thromboprophylaxis

Emergency Situations

• If emergency surgery becomes necessary, rivaroxaban should be stopped at least 24 hours before the procedure 3
• For urgent procedures with elevated rivaroxaban levels, prothrombin complex concentrate (PCC) may be considered 4

Algorithm for Management

1. Stop rivaroxaban 2 days before surgery (skip 1 dose)
2. Perform face lift surgery
3. Assess for hemostasis and bleeding risk 48 hours after surgery
4. If hemostasis is adequate, resume rivaroxaban at 10 mg once daily for 2 days
5. Increase to full therapeutic dose after 2 days of reduced dosing
6. If hemostasis is inadequate at 48 hours, reassess every 24 hours until safe to resume

This approach balances the competing risks of thromboembolism and surgical bleeding in this high-risk patient with moderate renal impairment.