What is the recommended bridging regimen for Xarelto (rivaroxaban) with Lovenox (enoxaparin) in high-risk patients undergoing face lift surgery?

Bridging Rivaroxaban (Xarelto) with Enoxaparin (Lovenox) for High-Risk Patients Undergoing Face Lift Surgery

For high-risk patients undergoing face lift surgery, bridging therapy with enoxaparin is not recommended when interrupting rivaroxaban therapy. 1 Instead, properly timed discontinuation and resumption of rivaroxaban is the preferred approach.

Discontinuation Protocol for Rivaroxaban

• Stop rivaroxaban 3 days before surgery (for patients with normal renal function)

  • If once-daily regimen with morning intake: Last dose on morning of day before procedure
  • If once-daily regimen with evening intake: Last dose two days before procedure
  • If twice-daily regimen: Last intake on morning of day before procedure 1

• Extended discontinuation periods for special circumstances:

  • For patients with moderate renal impairment (CrCl 30-50 mL/min): Stop 4 days before surgery
  • For patients with severe renal impairment (CrCl 15-29 mL/min): Stop 5 days before surgery 2
  • For very high bleeding risk procedures (such as neuraxial anesthesia): Up to 5 days discontinuation 2

No Bridging Recommendation

The French Working Group on Perioperative Hemostasis (GIHP) explicitly states that "preoperative bridging by UFH or LMWH is not recommended" when interrupting direct oral anticoagulants (DOACs) like rivaroxaban 1. This recommendation is supported by evidence showing:

• Increased bleeding risk in patients bridged with heparin products during invasive procedures
• No demonstrated benefit regarding thromboembolic risk 1

Resumption Protocol

1. Resume rivaroxaban at least 6 hours after the end of the procedure if there is no ongoing bleeding or surgical contraindication:

   • If once-daily evening regimen: Resume the evening of surgery day
   • If once-daily morning regimen: Resume the next morning
   • If twice-daily regimen: Resume the evening of surgery day 1

2. For higher bleeding risk situations:

   • If there is ongoing bleeding or surgical contraindication, delay resumption
   • Consider starting with prophylactic doses of LMWH first, then transitioning to rivaroxaban 2

Risk Assessment Considerations

While the American College of Chest Physicians provides risk stratification for patients on warfarin 1, these specific bridging recommendations do not apply to DOACs like rivaroxaban. For rivaroxaban, the key factors are:

• Thromboembolic risk: Assess patient's underlying condition (atrial fibrillation, mechanical heart valve, history of VTE)
• Bleeding risk: Face lift surgery carries moderate bleeding risk
• Renal function: Affects elimination of rivaroxaban and determines discontinuation timeline

Common Pitfalls to Avoid

1. Unnecessary bridging: Bridging with enoxaparin when interrupting rivaroxaban increases bleeding risk without providing additional thromboembolic protection 1

2. Insufficient discontinuation time: Ensure adequate time off rivaroxaban before surgery based on renal function

3. Premature resumption: Resuming full-dose rivaroxaban too soon after surgery can increase bleeding risk

4. Failure to adjust for renal function: Patients with impaired renal function require longer discontinuation periods

5. Inadequate communication: Ensure coordination between surgeon, anesthesiologist, and prescribing physician regarding the perioperative anticoagulation plan

By following these evidence-based recommendations, high-risk patients undergoing face lift surgery can have appropriate perioperative management of rivaroxaban without the need for bridging with enoxaparin.