Bridging from Warfarin to Xarelto Preoperatively
You do not "bridge" from warfarin to Xarelto (rivaroxaban) preoperatively—instead, you stop warfarin 5 days before surgery, and then start Xarelto postoperatively once hemostasis is achieved. The term "bridging" specifically refers to using short-acting parenteral anticoagulants (like LMWH or heparin) to cover the period when warfarin is stopped, not transitioning between two oral anticoagulants. 1, 2
Preoperative Warfarin Management
Stopping Warfarin Before Surgery
Stop warfarin 5-6 days before major surgery to allow the INR to normalize, based on warfarin's 36-42 hour half-life requiring approximately 5 half-lives for adequate clearance. 3
Check INR the day before surgery and proceed if INR ≤1.5 for most procedures. 1, 4
If INR remains >1.5 but ≤1.8 the day before surgery, consider low-dose oral vitamin K (1-2.5 mg) to expedite normalization. 1
Determining Need for Heparin Bridging
Bridging with LMWH or heparin is only indicated for high thromboembolic risk patients, not as a routine transition to Xarelto. 3, 1
High-risk patients requiring bridging include: 1
- Recent VTE within 3 months
- Active cancer with VTE
- Mechanical heart valves
- Atrial fibrillation with high CHADS₂ score
- Antiphospholipid syndrome with recurrent thrombosis
Low-risk patients do NOT require bridging: 1
- Atrial fibrillation with low CHADS₂ score
- VTE more than 3 months ago
- No other major risk factors
If Bridging is Required (High-Risk Patients Only)
Start therapeutic LMWH when INR falls below 2.0, typically 3 days before surgery (e.g., enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily). 1
Give the last preoperative LMWH dose 24 hours before surgery at half the total daily dose. 1
Postoperative Management
Resuming Anticoagulation
Resume warfarin 12-24 hours after surgery when adequate hemostasis is established. 3, 1
If bridging was used, continue therapeutic LMWH until INR reaches ≥2.0 in the therapeutic range. 1
For high bleeding risk procedures, delay therapeutic LMWH for 48-72 hours, but prophylactic LMWH may be started 12 hours postoperatively. 1
Transitioning to Xarelto Postoperatively
When switching from warfarin to Xarelto after surgery: 2
Discontinue warfarin and start Xarelto as soon as INR is below 3.0 in adults (below 2.5 in pediatric patients) to avoid periods of inadequate anticoagulation. 2
This transition typically occurs several days postoperatively once warfarin has re-established therapeutic anticoagulation and the decision is made to switch to a DOAC.
Do not start Xarelto immediately postoperatively—wait until hemostasis is secure and you would normally restart anticoagulation (12-24 hours minimum, longer for high bleeding risk). 2
Critical Pitfalls to Avoid
Do not confuse "bridging" with "switching": Bridging uses parenteral anticoagulants temporarily; switching means changing from one oral agent to another. 1, 2
Do not start Xarelto preoperatively while stopping warfarin—this creates overlapping anticoagulation and increases bleeding risk without established benefit. 2
Do not bridge low-risk patients—this increases bleeding complications without reducing thrombotic events. 1
For minor procedures (dental, dermatologic, cataract surgery), continuing warfarin may be safer than stopping it, eliminating the need for any transition. 3, 1