What is the required duration to discontinue Xarelto (rivaroxaban) prior to a heart catheterization?

From the Guidelines

Xarelto (rivaroxaban) should be discontinued at least 48 hours before a heart catheterization procedure to minimize the risk of bleeding, as recommended by the most recent guidelines from the American College of Chest Physicians 1.

Key Considerations

• The duration of discontinuation may vary depending on the patient's kidney function and bleeding risk.
• For patients with normal kidney function, stopping Xarelto 24 hours before the procedure may be sufficient, but this should be determined by the cardiologist or physician performing the procedure.
• The temporary discontinuation of Xarelto is necessary to prevent bleeding during the invasive procedure.
• Patients should not stop taking Xarelto without medical guidance, as this could increase the risk of blood clots.

Evidence-Based Recommendation

The American College of Chest Physicians recommends a pharmacokinetic-based approach to discontinuing direct oral anticoagulants (DOACs) like Xarelto before elective surgery or procedures 1. This approach involves withholding DOACs for 2 full days before the procedure, which corresponds to approximately 60-68 hours from the last DOAC dose. However, for patients with low-to-moderate-bleed-risk procedures, withholding DOACs for 1 full day before the procedure may be sufficient.

Important Qualifying Remarks

• Patients with severely impaired renal function (creatinine clearance < 30 mL/min) or hepatic function may require a longer duration of pre-operative DOAC interruption.
• Patients taking drugs that inhibit CYP3A4 or P-glycoprotein pathways may also require a longer duration of pre-operative DOAC interruption.
• Measurement of DOAC levels before the surgery or procedure may be considered in patients who require urgent surgery, but this approach has practical limitations and uncertain clinical utility 1.

Clinical Guidance

The decision to discontinue Xarelto before a heart catheterization procedure should be made in consultation with the cardiologist or physician performing the procedure, taking into account the patient's individual circumstances and risk factors. The patient should be instructed to resume Xarelto as directed by their physician, usually within 24-48 hours after the procedure, to minimize the risk of blood clots.

From the FDA Drug Label

If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings and Precautions (5. 2)] .

The required duration to discontinue Xarelto (rivaroxaban) prior to a heart catheterization is at least 24 hours before the procedure 2.

From the Research

Discontinuation of Xarelto (Rivaroxaban) Prior to Heart Catheterization

• There are no research papers provided that directly address the required duration to discontinue Xarelto (rivaroxaban) prior to a heart catheterization 3, 4, 5, 6, 7.
• The studies provided focus on various aspects of cardiac catheterization, such as the timing of cardiac catheterization in relation to valve surgery 3, fasting prior to cardiac catheterization 4, renal dosage recommendations for rivaroxaban in patients with chronic kidney disease 5, the effects of withdrawing vs continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization 6, and reducing time in bed after cardiac catheterization 7.
• None of these studies provide information on the specific duration for discontinuing Xarelto (rivaroxaban) before a heart catheterization procedure.