How long should Xarelto (rivaroxaban) be held before a colonoscopy?

Timing of Rivaroxaban (Xarelto) Discontinuation Before Colonoscopy

For patients taking rivaroxaban (Xarelto), it should be discontinued at least 24 hours before colonoscopy for low-risk procedures and at least 48-72 hours before high-risk procedures like polypectomy, based on the patient's renal function.

Rivaroxaban Discontinuation Timeline

The timing for holding rivaroxaban depends on both the bleeding risk of the procedure and the patient's renal function:

For Low-Risk Colonoscopy (Diagnostic with or without biopsies)

• Normal renal function (CrCl ≥50 mL/min): Stop rivaroxaban 24 hours before the procedure 1
• Moderate renal impairment (CrCl 30-50 mL/min): Stop rivaroxaban 48 hours (2 days) before the procedure 1
• Severe renal impairment (CrCl 15-29.9 mL/min): Stop rivaroxaban 72 hours (3 days) before the procedure 1

For High-Risk Colonoscopy (Polypectomy, EMR, ESD)

• Normal renal function: Stop rivaroxaban 48-72 hours (2-3 days) before the procedure 2, 1
• Moderate renal impairment: Stop rivaroxaban 72-96 hours (3-4 days) before the procedure 1
• Severe renal impairment: Consider consultation with hematology for management 2, 1

Risk Stratification

Procedure-Related Bleeding Risk

• Low-risk procedures: Diagnostic colonoscopy with or without biopsies 2
• High-risk procedures: Colonoscopy with polypectomy, endoscopic mucosal resection (EMR), or endoscopic submucosal dissection (ESD) 2

Patient Thrombotic Risk

• Low risk: Atrial fibrillation without valvular disease, >3 months after venous thromboembolism 2
• High risk: Recent coronary stents, mechanical heart valves, recent thromboembolism 2

Perioperative Management Algorithm

1. Assess procedure bleeding risk (low vs. high)
2. Assess patient thrombotic risk (low vs. high)
3. Evaluate renal function using CrCl or eGFR
4. Determine timing of rivaroxaban discontinuation based on above factors
5. Check INR prior to procedure to ensure it's <1.5 if there are concerns about residual anticoagulant effect 2

Resumption of Rivaroxaban After Colonoscopy

The timing for resuming rivaroxaban depends on the bleeding risk of the procedure:

• Low bleeding risk procedures: Resume rivaroxaban 24 hours after the procedure 2
• High bleeding risk procedures: Resume rivaroxaban 48-72 hours after the procedure 2, 1

For patients at high thrombotic risk after high-risk procedures, consider:

• Starting with a reduced dose (10 mg once daily) for the first 1-2 days 2, 1
• Using prophylactic doses of LMWH (40 mg daily) 6-12 hours after surgery if hemostasis is adequate and rivaroxaban resumption must be delayed 1

Important Considerations

• No bridging therapy is typically needed when interrupting rivaroxaban, unless the patient has a very high thrombotic risk 1
• Colonoscopy preparation quality is optimal when the second portion begins 4-6 hours before the procedure and is completed at least 2 hours before the start 2
• Coordinate timing of both bowel preparation and anticoagulation discontinuation to optimize both safety and visualization during the procedure
• Post-procedure monitoring is essential, particularly for patients who underwent polypectomy, as delayed bleeding can occur

Common Pitfalls to Avoid

1. Not accounting for renal function when determining the discontinuation timeline
2. Resuming full-dose anticoagulation too early after high-risk procedures
3. Unnecessarily prolonged discontinuation in low-risk procedures, increasing thrombotic risk
4. Failing to coordinate the timing of bowel preparation with anticoagulation management

Remember that the quality of colonoscopy preparation is inversely related to the time between the last dose of bowel preparation and the procedure 2, so timing of both anticoagulation management and bowel preparation should be coordinated for optimal outcomes.