What is the recommended timing for discontinuing Xarelto (rivaroxaban) prior to surgery?

Xarelto (Rivaroxaban) Discontinuation Prior to Surgery

For most surgical procedures, discontinue Xarelto at least 24 hours before surgery, but extend this to 2-3 days for high bleeding risk procedures, with timing adjusted based on renal function. 1

Risk-Stratified Approach to Discontinuation

Low to Moderate Bleeding Risk Procedures

• Stop Xarelto 1 day (24 hours) before the procedure, with the last dose taken on the morning of the day before surgery 2, 1
• No bridging anticoagulation is required during this brief interruption period 2
• This applies to procedures where surgical hemostasis can be readily achieved 3

High Bleeding Risk Procedures

• Stop Xarelto 2-3 days before the procedure when surgical hemostasis cannot be performed safely and a window without anticoagulant is required 3, 2
• For patients with normal renal function (CrCl >50 mL/min): discontinue 3 days (72 hours) before surgery 3
• The last intake should be three days before the procedure, with day 0 being the day of the procedure 3

Very High Bleeding Risk Procedures

• For intracranial neurosurgery or neuraxial anesthesia/puncture: extend discontinuation up to 5 days before the procedure 3
• Consider biological monitoring of rivaroxaban levels if there is concern about residual anticoagulant effect 3

Renal Function Adjustments

Timing of interruption must account for creatinine clearance using the Cockcroft-Gault formula, as rivaroxaban has significant renal elimination 3, 2

• CrCl >50 mL/min: Standard 2-3 day discontinuation for high-risk procedures 3
• CrCl 30-50 mL/min: Consider extending the discontinuation period due to slower drug clearance 2
• CrCl <30 mL/min: Longer interruption periods are necessary 3

Additional Risk Factors Requiring Extended Hold

Consider longer interruption periods (up to 5 days) in patients with: 3

• Age >80 years
• Concomitant P-glycoprotein inhibitors (which increase rivaroxaban plasma concentrations)
• Concomitant CYP3A4 inhibitors
• Any additional risk of drug accumulation

Bridging Considerations

No preoperative heparin bridging is recommended when the standard interruption periods are applied, except in patients at very high thrombotic risk 3

• Unnecessary bridging increases bleeding risk without clear benefit 3
• Biological monitoring is not needed when recommended interruption periods are followed and there is no additional risk of drug accumulation 3

Resumption After Surgery

Resume Xarelto as soon as adequate hemostasis has been established, noting that the time to onset of therapeutic effect is short 1

• Low bleeding risk procedures: Resume at least 24 hours postoperatively 2
• High bleeding risk procedures: Resume 48-72 hours postoperatively once adequate hemostasis is confirmed 2
• If venous thromboprophylaxis is indicated immediately post-surgery, heparin (UFH or LMWH) can be administered at least 6 hours after the procedure 3

Critical Pitfalls to Avoid

• Failing to obtain recent creatinine clearance measurement before determining hold duration can lead to inadequate drug clearance and increased bleeding risk 3, 2
• Not accounting for drug interactions with P-glycoprotein or CYP3A4 inhibitors may result in higher than expected rivaroxaban levels 3
• Unnecessarily prolonged discontinuation increases thrombotic risk without additional bleeding benefit 2
• Never perform neuraxial anesthesia in patients with possible residual rivaroxaban concentration due to insufficient discontinuation time 3