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

Rivaroxaban (Xarelto) Discontinuation Before Colonoscopy

For patients with normal renal function (CrCl ≥50 mL/min), rivaroxaban (Xarelto) should be discontinued 1-3 days before colonoscopy, with 2 days being optimal for most patients. 1

Factors Affecting Discontinuation Timing

The timing of rivaroxaban discontinuation depends on two key factors:

1. Renal Function:

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

2. Procedure Bleeding Risk:

   • Low-risk procedures (diagnostic colonoscopy with biopsies): 1-2 days
   • High-risk procedures (colonoscopy with polypectomy, EMR, ESD): 2-3 days 1

Practical Approach to Rivaroxaban Management

Pre-Procedure:

• Assess the patient's renal function using CrCl or eGFR
• Determine procedure bleeding risk (diagnostic vs. therapeutic colonoscopy)
• Evaluate patient's thrombotic risk (mechanical heart valves, recent VTE, etc.)
• For standard colonoscopy with potential polypectomy in patients with normal renal function, stop rivaroxaban 2 days before the procedure 1
• No bridging therapy with heparin is typically needed when interrupting rivaroxaban 1

Special Considerations:

• For patients at extremely high thrombotic risk (recent PE/DVT), consider bridging with enoxaparin starting 24 hours after the last rivaroxaban dose 1
• If bridging is used, administer the last dose of enoxaparin at least 24 hours before the procedure 1

Post-Procedure:

• Resume rivaroxaban 24 hours after low bleeding risk procedures
• Resume 48-72 hours after high bleeding risk procedures (e.g., large polypectomy) 1
• For high thrombotic risk patients after high-risk procedures, consider starting with a reduced dose (10 mg once daily) for the first 1-2 days 1

Common Pitfalls and Caveats

• Avoid same-day discontinuation: Unlike some antiplatelet agents, rivaroxaban requires at least 24 hours of discontinuation before procedures due to its bleeding risk 2
• Don't forget to check renal function: Patients with impaired renal function need longer discontinuation periods 1
• Consider procedure complexity: If multiple or large polyps are anticipated, longer discontinuation may be prudent
• Resumption timing matters: Restarting too early increases bleeding risk, while delaying too long increases thrombotic risk 1
• No laboratory monitoring needed: Unlike warfarin, routine laboratory monitoring of rivaroxaban concentration is not required when following recommended interruption periods 1

Comparison to Other Anticoagulants

For context, warfarin management differs significantly:

• Warfarin typically requires 5 days of discontinuation before high-risk procedures 3
• INR should be checked prior to the procedure to ensure it's <1.5 3
• For high thrombotic risk patients on warfarin, bridging with LMWH is recommended 3

By following these guidelines for rivaroxaban discontinuation before colonoscopy, you can minimize both bleeding and thrombotic risks while ensuring an effective procedure.