When to hold Xarelto (rivaroxaban) before surgery?

From the Guidelines

Xarelto (rivaroxaban) should be stopped 24-48 hours before surgery, depending on the bleeding risk of the procedure, with the most recent guidelines suggesting a pharmacokinetic-based approach to determine the interruption interval 1. For procedures with low bleeding risk, discontinuing Xarelto 24 hours before surgery may be sufficient, while for procedures with high bleeding risk, stopping Xarelto 48 hours before surgery is recommended. The decision to stop Xarelto should consider the patient's renal function, as impaired kidney function can lead to slower elimination of the drug. Key factors influencing the timing of Xarelto cessation include:

• The type of surgery and its associated bleeding risk
• The patient's renal function, with those having impaired renal function potentially requiring earlier cessation
• The need to balance the risk of bleeding during surgery against the risk of thromboembolic events After surgery, Xarelto can usually be restarted 24-48 hours later when adequate hemostasis has been achieved, but the exact timing should be determined by a healthcare provider considering the individual patient's conditions and risks 1. Some studies suggest that for patients with normal or mildly impaired renal function, stopping Xarelto 2 days before surgery (skipping 1 dose) may be adequate for low bleeding risk surgeries, while for high bleeding risk surgeries, stopping 3 days before surgery (skipping 2 doses) may be more appropriate 2, 3. However, the most recent and highest quality study should guide clinical decision-making, prioritizing a pharmacokinetic-based approach to minimize residual anticoagulant effect at the time of surgery while considering individual patient factors 1.

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)] . XARELTO should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established, noting that the time to onset of therapeutic effect is short [see Warnings and Precautions (5.1)] .

When to hold Xarelto (rivaroxaban) before surgery:

• XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding. 4

From the Research

Timing of Xarelto Discontinuation Before Surgery

• The decision to hold Xarelto (rivaroxaban) before surgery should be based on the type of surgery and the patient's individual risk factors, as indicated by 5.
• For spine surgery, it is recommended to stop Xarelto (Rivaroxaban) for at least 3 days prior to the operation, as stated in 5.
• The timing of discontinuation may vary depending on the patient's renal function, as rivaroxaban is metabolized and cleared via the kidney and liver, as noted in 6.
• Patients with severe renal impairment may require reduced dosages of rivaroxaban or alternative anticoagulants, as suggested by 7 and 8.

Considerations for Renal Impairment

• Rivaroxaban has been studied in patients with varying degrees of renal impairment, and the results suggest that it can be used in patients with severe renal impairment, as reported in 7.
• However, patients with renal impairment should be closely monitored, and their kidney function should be assessed prior to and during continued therapy with rivaroxaban, as recommended in 8.
• The pharmacokinetic profile of rivaroxaban suggests that concurrent use with neuraxial anesthesia should require no further precautions than currently necessary with low-molecular-weight heparin, as stated in 9.

General Guidelines

• The American Journal of Cardiovascular Drugs recommends that patients with chronic kidney disease should have their kidney function assessed prior to and during continued therapy with rivaroxaban, as stated in 7.
• The Journal of Clinical Pharmacology suggests that rivaroxaban is a viable option for anticoagulation in patients with cardiovascular disease and renal impairment, but the benefits and risks should be carefully assessed and balanced, as noted in 8.