Does rivaroxaban (Xarelto) require bridging with unfractionated heparin (UFH) or low molecular weight heparin (LMWH)?

From the Guidelines

Rivaroxaban does not require bridging with heparin when initiating therapy. Unlike warfarin, rivaroxaban has a rapid onset of action (2-4 hours) and achieves therapeutic anticoagulation quickly. When switching from heparin to rivaroxaban, the heparin should be discontinued and rivaroxaban started at the next scheduled heparin dose. Similarly, when transitioning from warfarin to rivaroxaban, warfarin should be discontinued and rivaroxaban started once the INR is below 3.0 (preferably below 2.5). For patients undergoing procedures, rivaroxaban should typically be stopped 24-48 hours before high-bleeding-risk procedures and 24 hours before low-bleeding-risk procedures, depending on renal function. After procedures, rivaroxaban can be restarted once hemostasis is achieved, usually within 24 hours for low-bleeding-risk procedures and 48-72 hours for high-bleeding-risk procedures. No bridging is needed during these interruptions due to rivaroxaban's predictable pharmacokinetics and short half-life (5-9 hours in healthy adults, 9-13 hours in elderly patients) 1. This simplified approach without bridging reduces the risk of bleeding complications while maintaining effective anticoagulation.

The 2019 AHA/ACC/HRS focused update on atrial fibrillation supports this approach, citing the Warfarin Therapy for an Elective Invasive Procedure or Surgery study, which found that absence of bridging was noninferior to bridging with low-molecular-weight heparin for prevention of arterial thromboembolism and decreased the risk of bleeding 1. Bridging anticoagulation may be appropriate only in patients (on warfarin) with a very high thromboembolic risk.

Key points to consider when using rivaroxaban include:

• Rapid onset of action and therapeutic anticoagulation
• No need for bridging with heparin when initiating therapy
• Discontinue heparin or warfarin when switching to rivaroxaban
• Stop rivaroxaban 24-48 hours before high-bleeding-risk procedures and 24 hours before low-bleeding-risk procedures
• Restart rivaroxaban once hemostasis is achieved after procedures
• Predictable pharmacokinetics and short half-life reduce the risk of bleeding complications.

From the FDA Drug Label

Switching from XARELTO to Warfarin – Adults: No clinical trial data are available to guide converting patients from XARELTO to warfarin. XARELTO affects INR, so INR measurements made during coadministration with warfarin may not be useful for determining the appropriate dose of warfarin One approach is to discontinue XARELTO and begin both a parenteral anticoagulant and warfarin at the time the next dose of XARELTO would have been taken.

Rivaroxaban (Xarelto) does not require bridging with unfractionated heparin (UFH) or low molecular weight heparin (LMWH) in all situations, but one approach to switching from XARELTO to warfarin is to discontinue XARELTO and begin both a parenteral anticoagulant and warfarin at the time the next dose of XARELTO would have been taken 2.

From the Research

Rivaroxaban Bridging Therapy

• Rivaroxaban does not necessarily require bridging with unfractionated heparin (UFH) or low molecular weight heparin (LMWH) in all cases, as stated in the study 3.
• The decision to bridge with heparin depends on the individual patient's risk of thrombosis and bleeding, as well as the type of procedure being performed 3.
• In patients with a high thrombosis and bleeding risk, anticoagulation should be bridged with UFH or LMWH 3.
• However, in patients not bridged with LMWH, the Biophen DiXaI LOW and STA LAX assays can be used to estimate rivaroxaban concentrations <50 ng/mL 4.
• Heparin bridging has been shown to increase the risk of non-major bleeding perioperatively in some cases 5.
• It is safe to stop rivaroxaban 8-28 hours before a procedure, and resuming the drug within 12 hours of the procedure is associated with a lower incidence of non-major bleeding 5.

Comparison of Anticoagulants

• High-dose rivaroxaban has been shown to be as effective as UFH and LMWH in preventing thrombus formation on mechanical heart valves in an in vitro study 6.
• Low-dose rivaroxaban, on the other hand, generated a massive thrombus generation and differed significantly from all other treatment groups regarding thrombus weight 6.
• Rivaroxaban has been associated with a significant reduction in the duration of hospital stay compared to standard therapy in patients with acute pulmonary embolism 7.