From the Guidelines
If a patient on Xarelto (rivaroxaban) is experiencing larger than normal bleeding from a wound, the medication should be temporarily held to prevent further exacerbation of the bleeding. This decision is based on the mechanism of action of Xarelto as an anticoagulant that inhibits blood clotting by blocking Factor Xa, and continuing it during active bleeding can worsen the hemorrhage 1. The management of bleeding in patients on oral anticoagulants, including Xarelto, has been outlined in the 2020 ACC expert consensus decision pathway, which suggests considering reversal/hemostatic agents for patients with major bleeding 1. For patients on Xarelto with major bleeding, andexanet alfa, a specific reversal agent, may be considered in a hospital setting, especially for life-threatening bleeding 1. Key considerations for the use of andexanet alfa include the timing of the last dose of Xarelto, the severity of the bleeding, and the patient's underlying thrombotic risk. Some important points to consider include:
- The decision to restart Xarelto should be made only after the bleeding is controlled and in consultation with a healthcare provider.
- For minor bleeding, local pressure and wound care may be sufficient, but for significant bleeding, medical attention should be sought immediately.
- The timing of restarting Xarelto depends on the severity of bleeding, the patient's underlying thrombotic risk, and the reason for anticoagulation, generally ranging from 24-72 hours after bleeding has stopped 1.
- Patients should never stop Xarelto without medical guidance, as this could increase the risk of blood clots, especially in those with atrial fibrillation or recent deep vein thrombosis. In cases where andexanet alfa is not available, other hemostatic agents like 4-factor prothrombin complex concentrate (4F-PCC) may be considered, although the evidence for its use in this context is more limited 1. Ultimately, the management of bleeding in patients on Xarelto requires a careful assessment of the individual patient's risk factors and the severity of the bleeding, as well as consultation with a healthcare provider to determine the best course of action.
From the FDA Drug Label
Discontinue XARELTO in patients with active pathological hemorrhage.
Xarelto should be discontinued if a patient has a larger than normal amount of blood coming from their wound, as this indicates active pathological hemorrhage. This is a precaution to minimize the risk of further bleeding, as XARELTO increases the risk of bleeding and can cause serious or fatal bleeding 2 2.
From the Research
Management of Bleeding with Xarelto
- The provided studies do not directly address the question of whether Xarelto should be held or given in cases of larger than normal amounts of blood coming from a wound 3, 4, 5, 6, 7.
- However, the studies suggest that rivaroxaban (Xarelto) can increase the risk of bleeding, particularly in elderly patients with venous thromboembolism (VTE) 3.
- A study on the efficacy and safety of rivaroxaban in elderly patients with VTE found that the total bleeding rate was 12.2%, with major bleeding and non-major clinically relevant bleeding occurring in 0.69% and 0.87% of patients, respectively 3.
- Another study on post-discharge prophylaxis with rivaroxaban found that extended-duration rivaroxaban resulted in a 28% reduction in fatal and major thromboembolic events, but also increased the risk of major bleeding 4.
- A systematic review on the control of severe, life-threatening external bleeding in the out-of-hospital setting found that tourniquets and hemostatic dressings were effective in controlling bleeding, but the certainty of evidence was very low 5.
- A pooled analysis of two randomized trials found that rivaroxaban 10 mg once daily for extended thromboprophylaxis after hospitalization for medical illness reduced the risk of major thromboembolic events, but increased the risk of fatal or critical site bleeding 6.
- A case study on hematoma of the lower extremity found that prompt recognition and operative evacuation of hematomas can help avoid significant complications such as tissue ischemia and necrosis 7.