How long should Xarelto (rivaroxaban) be held prior to colostomy reversal?

Rivaroxaban (Xarelto) Discontinuation Before Colostomy Reversal

Rivaroxaban (Xarelto) should be discontinued at least 24 hours before colostomy reversal surgery to reduce bleeding risk, with longer discontinuation periods required for patients with renal impairment or high bleeding risk procedures. 1

Perioperative Management of Rivaroxaban

Timing of Discontinuation

• For patients with normal renal function:
  • Low-to-moderate bleeding risk procedures: Hold rivaroxaban for at least 24 hours
  • High bleeding risk procedures: Hold rivaroxaban for at least 48 hours 2
• For patients with impaired renal function:
  • Longer discontinuation periods are necessary as rivaroxaban clearance is reduced

Bleeding Risk Assessment for Colostomy Reversal

• Colostomy reversal is generally considered a moderate-to-high bleeding risk procedure due to:
  • Potential for significant intraoperative bleeding
  • Risk of anastomotic complications
  • Extensive tissue dissection required

Resumption of Rivaroxaban

• Restart rivaroxaban only after adequate hemostasis has been established 1
• Typical resumption timing:
  • Low bleeding risk: 24 hours after procedure
  • High bleeding risk: 48-72 hours after procedure 3

Special Considerations

Bridging Anticoagulation

• Unlike warfarin, bridging with heparin or LMWH is typically not required when stopping rivaroxaban 2
• The short half-life of rivaroxaban (5-9 hours) allows for more straightforward perioperative management

Monitoring

• No specific laboratory test is routinely recommended to monitor rivaroxaban levels before surgery
• For urgent procedures, prothrombin time may provide useful information; a level close to control suggests a low serum concentration 2

Renal Function Assessment

• Evaluate renal function before surgery as rivaroxaban is partially cleared by the kidneys
• For patients with CrCl <30 mL/min, consider extending the discontinuation period beyond 24 hours

Potential Complications of Colostomy Reversal

While not directly related to anticoagulation management, it's important to note that colostomy reversal carries significant morbidity:

• Wound infection (reported in up to 19.8% of cases) 4
• Incisional hernia (up to 15.6%) 4
• Anastomotic complications
• Intestinal obstruction 5

Proper anticoagulation management is critical to minimize bleeding complications while balancing thromboembolic risk.

Practical Algorithm for Rivaroxaban Management Before Colostomy Reversal

1. Assess patient's renal function and bleeding risk
2. For normal renal function:
   • Hold rivaroxaban for at least 24 hours before surgery 1
   • For high bleeding risk or complex colostomy reversal, consider holding for 48 hours
3. For impaired renal function (CrCl <50 mL/min):
   • Extend discontinuation period to at least 48 hours
4. Resume rivaroxaban only after adequate hemostasis is achieved, typically 24-72 hours post-procedure depending on bleeding risk 3

Remember that the timing of rivaroxaban resumption is crucial, as the anticoagulant effect begins within 2-4 hours of administration, which is much faster than warfarin.