How many days should Xarelto (rivaroxaban) be held prior to a colonoscopy?

Timing of Rivaroxaban (Xarelto) Discontinuation Before Colonoscopy

Rivaroxaban (Xarelto) should be discontinued 3 days before colonoscopy for patients with normal renal function (CrCl >30 mL/min). 1

Discontinuation Protocol Based on Bleeding Risk

Low Bleeding Risk Colonoscopy

• For patients on once-daily rivaroxaban regimen (morning dose): Last dose should be taken on the morning of the day before the procedure 1
• For patients on once-daily rivaroxaban regimen (evening dose): Last dose should be taken two days before the procedure 1
• For patients on twice-daily rivaroxaban regimen: Last dose should be taken on the morning of the day before the procedure 1

High Bleeding Risk Colonoscopy (including polypectomy)

• Rivaroxaban should be discontinued 3 days before the procedure (day 0 being the procedure day) for patients with creatinine clearance >30 mL/min 1
• No bridging with heparin is recommended during this interruption period 1
• Check that rivaroxaban has adequately cleared before the procedure (though specific testing is not routinely required) 1

Considerations for Special Populations

Renal Function Adjustments

• For patients with impaired renal function (CrCl 30-50 mL/min), consider a longer discontinuation period 1
• Patients with severely impaired renal function may require additional days of discontinuation due to prolonged drug clearance 1

Very High Bleeding Risk Procedures

• For procedures with very high bleeding risk, consider discontinuing rivaroxaban for up to 5 days prior to the procedure 1

Resumption Protocol After Colonoscopy

• For low bleeding risk colonoscopy without polypectomy: Resume rivaroxaban at least 6 hours after the procedure 1

  • Evening dose regimen: Resume the evening of the procedure day
  • Morning dose regimen: Resume the next morning after the procedure
  • Twice daily regimen: Resume the evening of the procedure day

• For high bleeding risk colonoscopy or after polypectomy: Resume rivaroxaban 24-72 hours after the procedure, once adequate hemostasis is confirmed 1

Important Considerations

• The FDA label for Xarelto states that it should be stopped at least 24 hours before any procedure to reduce bleeding risk, but this is a minimum recommendation 2
• Colonoscopy with potential polypectomy requires a longer discontinuation period due to the increased bleeding risk 1, 3
• No preoperative bridging with heparin is recommended for most patients 1
• The half-life of rivaroxaban is 5-9 hours in healthy subjects and 11-13 hours in elderly subjects, requiring appropriate discontinuation timing 4

Common Pitfalls to Avoid

• Failing to account for renal function when determining discontinuation timing 1
• Resuming anticoagulation too early after polypectomy, which may increase bleeding risk 3
• Unnecessarily prolonged discontinuation, which may increase thrombotic risk 1
• Inadequate bowel preparation, which may necessitate earlier repeat colonoscopy regardless of anticoagulation status 5

Following these evidence-based guidelines for rivaroxaban management around colonoscopy will help optimize both bleeding risk and thrombotic risk for patients.