When to hold Xarelto (Rivaroxboxing) for surgery?

From the Guidelines

Xarelto (rivaroxaban) should be stopped 48 hours before surgery for high bleeding risk procedures and 24 hours before surgery for low bleeding risk procedures, as suggested by the most recent and highest quality study 1. The management of Xarelto before surgery depends on the bleeding risk of the procedure and the patient's renal function.

• For patients with normal or mildly impaired renal function, Xarelto can be stopped 24-48 hours before surgery, depending on the bleeding risk of the procedure.
• For patients with moderately impaired renal function, a longer duration of interruption may be required, typically 3-4 days before surgery.
• The timing of discontinuation is critical because Xarelto is a direct factor Xa inhibitor with a relatively short half-life of 5-9 hours in healthy adults, and it directly affects the blood's ability to clot.
• After surgery, Xarelto can usually be resumed 24-48 hours post-procedure once adequate hemostasis is achieved, but the resumption may be delayed for 48-72 hours for procedures with high bleeding risk.
• It is essential to consult with both the surgeon and the physician who prescribed Xarelto before making any changes to the medication regimen, as individual factors may require personalized adjustments to this general guidance, as noted in 1 and 1. Some studies suggest that the preoperative interruption of Xarelto can be based on a pharmacokinetic approach, taking into account the drug's half-life and renal clearance, as discussed in 1 and 1. However, the most recent and highest quality study 1 provides a more straightforward approach, recommending a 48-hour interruption before high bleeding risk procedures and a 24-hour interruption before low bleeding risk procedures. It is crucial to consider the patient's individual factors, such as renal function and bleeding risk, when determining the optimal timing for Xarelto interruption and resumption, as emphasized in 1 and 1.

From the FDA Drug Label

If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, rivaroxaban tablets should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings and Precautions (5. 2)]. In deciding whether a procedure should be delayed until 24 hours after the last dose of rivaroxaban tablets, the increased risk of bleeding should be weighed against the urgency of intervention Rivaroxaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established, noting that the time to onset of therapeutic effect is short [see Warnings and Precautions (5.1)].

Holding Xarelto for Surgery: Rivaroxaban tablets should be stopped at least 24 hours before a surgical procedure to reduce the risk of bleeding. The decision to delay a procedure should weigh the increased risk of bleeding against the urgency of the intervention. Rivaroxaban tablets can be restarted after the procedure once adequate hemostasis has been established 2.

From the Research

Holding Xarelto for Surgery

• The decision to hold Xarelto (rivaroxaban) for surgery depends on various factors, including the type of surgery, patient's risk of bleeding, and risk of venous thromboembolism (VTE) 3, 4.
• Studies have shown that rivaroxaban can be safely initiated 12-24 hours after the last dose of low molecular weight heparin (LMWH) in patients undergoing total hip or knee replacement surgery 4.
• In patients with lower limb fractures, rivaroxaban has been shown to be effective and safe in preventing VTE, with a lower incidence of symptomatic VTE compared to LMWH 5.
• A meta-analysis of randomized controlled trials found no statistically significant difference in the preventive effect against VTE or bleeding events when using rivaroxaban or LMWH in non-major orthopedic surgery 6.
• The European Medicine Equivalence Agency (EMEA) has assessed the safety and efficacy of rivaroxaban, and studies have shown that it exhibits an increased risk of major and clinically relevant bleeding compared to enoxaparin 3.
• The timing of the first administration of rivaroxaban is important, and it is recommended to initiate it approximately 12 or 24 hours after the last LMWH dose, as appropriate 4.

Considerations for Holding Xarelto

• Patient's age and renal function should be considered when holding Xarelto, as rivaroxaban has been shown to have increased pharmacodynamic effects in older patients and those with reduced renal function 4.
• The risk of bleeding and VTE should be carefully evaluated in each patient, and the decision to hold Xarelto should be made on a case-by-case basis 3, 4, 5, 6.
• The dosing regimen and practical administration of rivaroxaban should also be considered, as it has a narrower therapeutic index compared to LMWH 3.