What is the recommended hold time for Xarelto (rivaroxaban) prior to eye surgery?

Rivaroxaban (Xarelto) Hold Time Prior to Eye Surgery

For patients taking rivaroxaban (Xarelto) who require eye surgery, the medication should be discontinued 1 day before low-to-moderate bleeding risk procedures and 2 days before high bleeding risk procedures, according to the American College of Chest Physicians guidelines. 1

Bleeding Risk Stratification for Eye Surgery

Eye surgeries can be categorized based on bleeding risk:

• Low-to-moderate bleeding risk eye procedures:

  • Cataract surgery
  • Intravitreal injections
  • Most glaucoma procedures
  • Routine retinal laser procedures

• High bleeding risk eye procedures:

  • Retinal/vitreous surgery
  • Orbital surgery
  • Oculoplastic procedures
  • Corneal transplantation

Specific Recommendations for Rivaroxaban Discontinuation

Based on Procedure Bleeding Risk

• Low-to-moderate bleeding risk procedures:

  • Hold rivaroxaban for 1 day (24 hours) before the procedure 1
  • Last dose should be taken 2 days before surgery (skip one day)

• High bleeding risk procedures:

  • Hold rivaroxaban for 2 days before the procedure 1
  • Last dose should be taken 3 days before surgery (skip two days)

Renal Function Considerations

Unlike dabigatran, which requires longer hold times with decreased renal function, the standard hold times for rivaroxaban are generally sufficient regardless of renal function, unless severe impairment exists 1.

Resumption of Rivaroxaban After Eye Surgery

• Low-to-moderate bleeding risk procedures:

  • Resume rivaroxaban at least 24 hours after surgery when adequate hemostasis is achieved 1, 2

• High bleeding risk procedures:

  • Resume rivaroxaban 48-72 hours after surgery when adequate hemostasis is achieved 1, 3

Important Considerations

• No bridging needed: The rapid offset and onset of action of rivaroxaban eliminates the need for bridging with heparin or low molecular weight heparin 1

• Emergency procedures: If emergency eye surgery is required and rivaroxaban cannot be discontinued for the recommended period, the increased risk of bleeding should be weighed against the urgency of the procedure 2

• Monitoring: For emergency situations, rivaroxaban plasma concentrations can be assessed using anti-Factor Xa chromogenic assays or prothrombin time assays with rivaroxaban-sensitive reagents 4

• Reversal: In case of life-threatening bleeding complications, prothrombin complex concentrate may be considered 5

Practical Algorithm for Perioperative Management

1. Determine bleeding risk of the eye procedure
2. Calculate appropriate hold time:
   • Low/moderate risk: Hold 1 day (24 hours) before procedure
   • High risk: Hold 2 days (48 hours) before procedure
3. Resume rivaroxaban:
   • Low/moderate risk: Resume ≥24 hours post-procedure
   • High risk: Resume 48-72 hours post-procedure
4. Ensure adequate hemostasis before resumption

This approach aligns with the 2022 American College of Chest Physicians guidelines for perioperative management of antithrombotic therapy, which provides the most current and authoritative recommendations for managing rivaroxaban in the perioperative setting 1.