How to bridge Xarelto (rivaroxaban) with Lovenox (enoxaparin) in high-risk patients undergoing surgery?

Bridging Rivaroxaban with Enoxaparin in High-Risk Patients for Surgery

For high-risk thromboembolism patients undergoing surgery, bridging therapy with enoxaparin is generally not recommended when interrupting rivaroxaban, as this increases bleeding risk without reducing thromboembolism risk. 1

Discontinuation of Rivaroxaban Before Surgery

The timing of rivaroxaban discontinuation depends on:

1. Bleeding risk of the procedure
2. Patient's renal function

For High Bleeding Risk Procedures:

• Normal renal function (CrCl ≥50 mL/min): Stop rivaroxaban 3 days before surgery 2
• Moderate renal impairment (CrCl 30-50 mL/min): Stop rivaroxaban 4 days before surgery 2
• Severe renal impairment (CrCl 15-29.9 mL/min): Stop rivaroxaban 5 days before surgery 1

For Very High Bleeding Risk Procedures (e.g., intracranial neurosurgery, neuraxial anesthesia):

• Longer interruption times are required - up to 5 days for rivaroxaban 2

When to Consider Bridging with Enoxaparin

Bridging therapy should be limited to patients at extremely high thrombotic risk, such as:

• Recent history of pulmonary embolism or deep venous thrombosis (within 3 months)
• Recent stroke or TIA (within 3 months)
• Mechanical heart valve in mitral position
• Multiple prior thromboembolic events

How to Bridge with Enoxaparin (When Absolutely Necessary)

1. Discontinue rivaroxaban according to the schedule above
2. Start enoxaparin when rivaroxaban effect is minimal:
   • Begin 24 hours after the last rivaroxaban dose
   • Use therapeutic dose for high-risk patients (1 mg/kg twice daily or 1.5 mg/kg once daily)
3. Stop enoxaparin before surgery:
   • Last dose 24 hours before surgery
   • Use half the therapeutic dose for the last injection

Resumption of Anticoagulation After Surgery

1. For high bleeding risk procedures:

   • Resume rivaroxaban 48-72 hours after surgery 1
   • Consider starting with prophylactic dose enoxaparin (40 mg daily) 6-12 hours after surgery if hemostasis is adequate
   • Transition to rivaroxaban once bleeding risk decreases (typically 2-3 days post-op)

2. For standard bleeding risk procedures:

   • Resume rivaroxaban at least 6 hours after the end of the procedure if there is no ongoing bleeding 2
   • For once-daily regimen: resume the evening (evening intake) or next morning (morning intake)
   • For twice-daily regimen: resume the evening of the same day

Important Considerations

• No routine laboratory monitoring of rivaroxaban is required when following the recommended interruption periods 1
• Avoid neuraxial anesthesia if there is insufficient discontinuation time for rivaroxaban 2
• Balance thrombotic vs. bleeding risk - early resumption increases bleeding risk while delayed resumption increases thromboembolism risk 1

Common Pitfalls to Avoid

1. Unnecessary bridging - most patients don't need bridging therapy when stopping rivaroxaban
2. Overlapping anticoagulants - ensure adequate time between stopping enoxaparin and starting rivaroxaban
3. Ignoring renal function - rivaroxaban clearance is affected by kidney function
4. Resuming full-dose anticoagulation too early - consider prophylactic doses first when bleeding risk is high

By following these guidelines, you can effectively manage the perioperative anticoagulation needs of high-risk patients on rivaroxaban requiring surgery while minimizing both bleeding and thrombotic complications.