How long prior to surgery should you hold Xarelto (rivaroxaban) for a patient with a history of Deep Vein Thrombosis (DVT)?

Perioperative Management of Rivaroxaban in Patients with History of DVT

For patients with a history of DVT on rivaroxaban (Xarelto), hold the medication for 1 day before low-to-moderate bleeding risk procedures and 2 days before high bleeding risk procedures. 1

Discontinuation Timing Based on Procedure Bleeding Risk

Low-to-Moderate Bleeding Risk Procedures

• Hold rivaroxaban for 1 day before the procedure 1
• Examples include:
  • Diagnostic endoscopy
  • Colonoscopy with biopsy
  • Coronary angiography (especially with radial approach) 2

High Bleeding Risk Procedures

• Hold rivaroxaban for 2 days before the procedure 1
• Examples include:
  • Neuraxial procedures (spinal/epidural anesthesia)
  • Major surgery
  • Cardiac/intracranial/spinal surgery
  • Major organ surgery
  • Colonoscopy with polypectomy 2

Very High Bleeding Risk Procedures

• For intracranial neurosurgery or neuraxial anesthesia/puncture, a longer interruption time of up to 5 days may be needed 1

Special Considerations

Renal Function

• The standard discontinuation timing applies to patients with normal renal function (CrCl ≥50 mL/min)
• For patients with moderate renal impairment (CrCl 30-50 mL/min), consider extending the interruption period 2
• For severe renal impairment (CrCl <30 mL/min), hematology consultation is recommended 2

No Need for Bridging

• The rapid offset and onset of action of rivaroxaban eliminates the need for heparin bridging in most perioperative settings 1
• Exception: Consider bridging only for patients at extremely high thrombotic risk (e.g., very recent DVT) 2

Resumption of Anticoagulation

• For low-to-moderate bleeding risk procedures: Resume rivaroxaban at least 24 hours after the procedure 1
• For high bleeding risk procedures: Resume rivaroxaban 48-72 hours after the procedure 1
• If venous thromboprophylaxis is indicated immediately post-procedure, consider using prophylactic dose heparin or LMWH starting 6 hours after the procedure until rivaroxaban can be safely resumed 1

Important Caveats

• Rivaroxaban has a rapid onset of action (peak effect 1-3 hours after intake), requiring cautious administration after surgery 1
• No routine laboratory monitoring is required when following these recommended interruption periods 2
• For urgent/emergency procedures, DOAC level testing may be considered to determine the need for reversal agents 1
• The timing recommendations apply regardless of whether rivaroxaban is being used for atrial fibrillation or VTE treatment 1

Following these evidence-based guidelines will help balance the risks of perioperative bleeding against thrombotic complications in patients with a history of DVT who are on rivaroxaban therapy.