What should be done after rivaroxaban (Xarelto) is suspended?

Resumption of Rivaroxaban After Suspension

After rivaroxaban (Xarelto) has been suspended, it should be resumed based on the bleeding risk of the procedure and the patient's thromboembolic risk, with timing of 24 hours post-procedure for low bleeding risk procedures and 48-72 hours for high bleeding risk procedures. 1

Timing of Rivaroxaban Resumption

The resumption of rivaroxaban after temporary interruption depends on several key factors:

Based on Procedural Bleeding Risk:

• Low bleeding risk procedures:

  • Resume rivaroxaban 24 hours after the procedure 1
  • Use full therapeutic dose (20 mg once daily) 1

• High bleeding risk procedures:

  • Resume rivaroxaban 48-72 hours after the procedure 1
  • Consider using a reduced dose (10 mg once daily) for the first 2-3 days before returning to the full therapeutic dose 1

Patient-Specific Considerations

Thromboembolic Risk Assessment:

• For patients at high risk for thromboembolism (mechanical valves, recent stroke, CHA₂DS₂-VASc score ≥2):
  • Consider earlier resumption with reduced dosing 1
  • For very high-risk patients, consider bridging with prophylactic dose heparin or LMWH starting 6 hours post-procedure until rivaroxaban can be safely resumed 1

Renal Function:

• Normal renal function: Follow standard resumption timing
• Impaired renal function (GFR <60 mL/min): Be aware that drug clearance is reduced, potentially leading to higher-than-expected residual drug concentrations 2
• Severe renal impairment: Consider hematology consultation before resumption 3

Special Scenarios

After Coronary Intervention:

• If the patient has undergone PCI and requires dual antiplatelet therapy:
  • Consider a double-therapy regimen (rivaroxaban plus P2Y12 inhibitor) rather than triple therapy 1
  • If full-dose rivaroxaban was reduced during the dual therapy period, resume the full recommended dose (20 mg once daily, or 15 mg once daily in patients with creatinine clearance of 30-49 mL/min) after suspension of antiplatelet therapy 1

Missed Doses:

If the patient misses a dose during the resumption period:

• For once-daily dosing: Take the missed dose immediately on the same day when noticed 4
• Do not double the dose to make up for a missed dose 4

Important Precautions

• Premature discontinuation risk: Be aware that premature discontinuation of rivaroxaban without adequate alternative anticoagulation increases the risk of thrombotic events 4
• Drug interactions: Use caution when resuming rivaroxaban in patients taking medications that affect CYP3A4, CYP2J2, or P-glycoprotein, particularly amiodarone, which can lead to higher-than-expected drug concentrations 2
• Monitoring: Standard coagulation tests are not reliable for monitoring rivaroxaban activity; specific anti-Xa assays can be considered if concerned about residual anticoagulant effect 3

Practical Approach

1. Assess procedural bleeding risk (low vs. high)
2. Evaluate patient's thromboembolic risk
3. Consider renal function and potential drug interactions
4. Select appropriate timing and dosing for resumption
5. Provide clear instructions to the patient about when and how to resume medication

Following these guidelines will help ensure safe and effective resumption of rivaroxaban therapy after temporary suspension while minimizing both bleeding and thrombotic risks.