Timing of Xarelto Initiation After Discontinuing Heparin Drip
After discontinuing a heparin drip, you should start Xarelto (rivaroxaban) 0 to 2 hours after stopping the heparin infusion.
Evidence-Based Recommendation
The FDA drug label for Xarelto (rivaroxaban) provides clear guidance on transitioning from unfractionated heparin to rivaroxaban. According to the label, when switching from unfractionated heparin being administered by continuous infusion, you should stop the infusion and start Xarelto at the same time 1.
For more specific timing:
- Stop the heparin infusion
- Start Xarelto 0-2 hours after discontinuing the heparin infusion
- No overlap period is required between heparin and Xarelto
Rationale and Pharmacokinetics
This recommendation is based on the following considerations:
Rapid onset of action: Xarelto has a quick onset of therapeutic effect, reaching peak plasma concentrations within 2-4 hours after administration.
Avoiding anticoagulation gaps: The recommendation to start Xarelto shortly after stopping heparin prevents periods of inadequate anticoagulation that could increase thrombotic risk.
Preventing excessive anticoagulation: Starting Xarelto too soon (with significant overlap) could potentially increase bleeding risk due to the combined anticoagulant effects.
Special Considerations
Renal Function
- Assess renal function before initiating Xarelto, as dose adjustments may be necessary for patients with renal impairment.
- For patients with creatinine clearance <30 mL/min, Xarelto should be used with caution.
Specific Clinical Scenarios
For patients with heparin-induced thrombocytopenia (HIT):
- Rivaroxaban has been studied as a treatment option for HIT with promising results 2, 3.
- In patients with confirmed HIT, rivaroxaban at 15 mg twice daily until platelet recovery, followed by 20 mg daily, has been shown to be effective 2.
Common Pitfalls to Avoid
Delaying Xarelto initiation: Waiting too long after stopping heparin may create a window of inadequate anticoagulation, increasing thrombotic risk.
Unnecessary bridging: Unlike transitioning to warfarin, no bridging period is needed when switching from heparin to Xarelto.
Monitoring confusion: Unlike heparin, which requires aPTT monitoring, Xarelto does not require routine coagulation monitoring. Discontinue aPTT monitoring after stopping heparin.
Dosing errors: Ensure the appropriate Xarelto dose based on the indication. For most venous thromboembolism treatments, the initial dose is 15 mg twice daily for 21 days, followed by 20 mg once daily.
Conclusion
The evidence strongly supports starting Xarelto 0-2 hours after discontinuing a heparin infusion. This approach ensures continuous anticoagulation while minimizing the risk of both thrombotic events and bleeding complications.