How long should Xarelto (rivaroxaban) be held prior to foot surgery?

Rivaroxaban Discontinuation Protocol for Foot Surgery

For foot surgery, rivaroxaban (Xarelto) should be discontinued 2 days before the procedure if the bleeding risk is high, or 1 day before if the bleeding risk is low to moderate. 1

Discontinuation Timeline Based on Bleeding Risk

Low to Moderate Bleeding Risk Foot Surgery

• Discontinue rivaroxaban 1 day before the procedure 1
• Last dose should be taken on the morning of the day before surgery 2
• No bridging with heparin is required during this interruption period 1

High Bleeding Risk Foot Surgery

• Discontinue rivaroxaban 2 days before the procedure 1
• For patients with impaired renal function (CrCl 30-50 mL/min), consider extending the discontinuation period 1
• For very high bleeding risk procedures (e.g., neuraxial anesthesia), discontinuation for up to 5 days may be necessary 1

Special Considerations

Renal Function Assessment

• Standard discontinuation times apply to patients with normal renal function (CrCl >30 mL/min) 1
• For patients with impaired renal function, longer discontinuation periods are recommended due to slower drug clearance 1
• Timing of interruption should account for creatinine clearance (CrCl using Cockcroft and Gault formula) 1

Dosing Schedule Considerations

• For once-daily morning dosing: Last dose should be taken on the morning of the day before the procedure 2
• For once-daily evening dosing: Last dose should be taken two days before the procedure 2
• For twice-daily dosing: Last dose should be taken on the morning of the day before the procedure 2

Resumption Protocol After Foot Surgery

• For low 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, once adequate hemostasis is confirmed 1
• If oral medication cannot be taken immediately after surgery, consider administering parenteral anticoagulation until oral intake is possible 3

Important Pitfalls to Avoid

• Failing to account for renal function when determining discontinuation timing, which could lead to increased bleeding risk 1
• Unnecessarily prolonged discontinuation, which may increase thrombotic risk 1
• Resuming rivaroxaban too early after high bleeding risk procedures before adequate hemostasis is achieved 1
• Not considering the rapid onset of action of rivaroxaban (peak effect 1-3 hours after intake) when planning resumption 1
• Overlooking the need for thromboprophylaxis in foot surgery patients requiring cast immobilization and non-weight bearing, who have a higher VTE risk (8.46%) 4

Specific Considerations for Foot Surgery

• Foot surgery requiring non-weight bearing in combination with short leg cast immobilization carries a higher risk of VTE, warranting careful consideration of anticoagulation resumption timing 4
• The average timing to diagnosis of VTE after foot surgery is approximately 33 days, suggesting the importance of appropriate anticoagulation management during the postoperative period 4
• Rivaroxaban should be restarted after surgical procedures as soon as adequate hemostasis has been established 3