How long should Xarelto (rivaroxaban) be stopped before hip replacement surgery in patients with normal or impaired renal function?

Preoperative Management of Xarelto (Rivaroxaban) Before Hip Replacement

For hip replacement surgery, stop Xarelto (rivaroxaban) at least 48 hours (2 days) before surgery if creatinine clearance is ≥50 mL/min, or 48-72 hours if CrCl is 30-49 mL/min, with no bridging anticoagulation required. 1

Risk Classification

Hip replacement is classified as a high bleeding risk procedure that requires minimal to no residual anticoagulant effect at the time of surgery. 1 This classification determines the duration of rivaroxaban interruption needed to ensure adequate drug clearance.

Timing Based on Renal Function

The duration of rivaroxaban interruption must be adjusted according to the patient's creatinine clearance (CrCl), as renal function directly affects drug elimination:

Normal or Mildly Impaired Renal Function (CrCl ≥50 mL/min)

• Stop rivaroxaban ≥48 hours before surgery (skip 2 doses for once-daily dosing). 1
• This corresponds to 4-5 drug half-lives, achieving minimal residual anticoagulation. 1

Moderate Renal Impairment (CrCl 30-49 mL/min)

• Stop rivaroxaban ≥48 hours before surgery, though some guidelines recommend extending to 72 hours (3 days). 1
• The longer duration accounts for prolonged drug elimination in reduced renal function. 1

Severe Renal Impairment (CrCl 15-29 mL/min)

• Stop rivaroxaban 36-48 hours before surgery for standard procedures, though hip replacement may warrant longer interruption. 1
• Consider extending to 72-96 hours (3-4 days) given the high bleeding risk of hip surgery. 1

Critical Timing Considerations

Obtain a recent creatinine clearance measurement before determining the hold duration to ensure accurate dosing decisions. 1 The Cockcroft-Gault formula should be used for CrCl calculation. 1

Additional Risk Factors Requiring Extended Hold

Consider extending the interruption period (up to 5 days) in patients with: 1

• Age >80 years
• Concomitant P-glycoprotein inhibitors (e.g., dronedarone, amiodarone, verapamil)
• Any additional risk of drug accumulation

For patients taking P-glycoprotein inhibitors, adding an extra 24 hours of interruption may be advisable, especially if thromboembolic risk is not very high. 1

Bridging Anticoagulation

Do not use preoperative bridging with low molecular weight heparin (LMWH) or unfractionated heparin in patients stopping rivaroxaban for hip replacement. 1 The predictable pharmacokinetics of rivaroxaban allow for properly timed short-term cessation without bridging. Mixing two anticoagulants has been associated with increased bleeding risk. 1

The only exception is patients at very high thrombotic risk, where bridging may be considered on a case-by-case basis. 1

Perioperative Monitoring

Biological monitoring of rivaroxaban levels is generally not needed when recommended interruption periods are followed and there is no additional risk of drug accumulation. 1 However, measurement of rivaroxaban plasma levels may be considered in cases where prediction of drug clearance is unclear due to combined risk factors. 1

FDA-Approved Guidance

The FDA label states: "If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, XARELTO should be stopped at least 24 hours before the procedure." 2 However, this represents a minimum threshold; for high bleeding risk procedures like hip replacement, the longer durations specified above (48-72 hours) are more appropriate. 1

Resumption After Surgery

Resume rivaroxaban 48-72 hours after hip replacement surgery, provided adequate hemostasis has been established and there is no ongoing bleeding. 1

• If VTE prophylaxis is needed immediately postoperatively, use LMWH or fondaparinux starting at least 6 hours after surgery. 1
• When restarting rivaroxaban, ensure at least 12 hours have elapsed since the last prophylactic LMWH dose to avoid overlapping anticoagulation. 1
• The time to onset of therapeutic effect with rivaroxaban is rapid once restarted. 2

Common Pitfalls to Avoid

• Do not use the 24-hour minimum hold time from the FDA label for high bleeding risk procedures like hip replacement; this is insufficient. 1
• Do not bridge with heparin products unless the patient has exceptionally high thrombotic risk. 1
• Do not forget to assess renal function before determining hold duration, as this is the primary determinant of drug clearance. 1
• Do not resume therapeutic-dose rivaroxaban too early postoperatively; wait 48-72 hours to ensure adequate surgical hemostasis. 1