Can a peri-operative patient take Airtel, Nubera, Xarelto (Rivaroxaban) 2.5mg, Clopidogrel 75mg, and Becosules?

Perioperative Management of Multiple Antithrombotic Medications

Direct Answer

This patient is taking a high-risk combination of anticoagulant (Xarelto/rivaroxaban 2.5mg) and antiplatelet (Clopilet/clopidogrel 75mg) medications that requires careful perioperative management based on bleeding risk, thrombotic risk, and surgical urgency. The other medications (Airtel/telmisartan, Nubera/nebivolol, Becosules/B-complex) can generally be continued perioperatively without significant bleeding concerns.

Risk Stratification Required

Assess Thrombotic Risk

• Determine the indication for dual antithrombotic therapy - rivaroxaban 2.5mg plus clopidogrel suggests either recent coronary intervention with stenting or peripheral artery disease with recent revascularization 1, 2
• For drug-eluting stents: Surgery should ideally be postponed for at least 6 months after stent placement; for bare-metal stents, postpone for at least 6 weeks 1
• If surgery cannot be delayed within these timeframes, a multidisciplinary discussion involving cardiology, surgery, and anesthesia is mandatory 1

Assess Bleeding Risk of Procedure

• Low bleeding risk procedures (dental extractions, cataract surgery, minor dermatologic procedures): Can often proceed without interrupting medications 1
• Intermediate bleeding risk: May require stopping clopidogrel while continuing aspirin (though this patient is on rivaroxaban, not aspirin) 1
• High bleeding risk procedures (major abdominal, orthopedic, neurosurgery): Require interruption of both agents 1

Management Protocol for Elective Surgery

Rivaroxaban (Xarelto) 2.5mg Management

For low bleeding risk procedures:

• Stop rivaroxaban the night before surgery 1
• Resume at least 6 hours after procedure if hemostasis is adequate 1, 3

For high bleeding risk procedures:

• Stop rivaroxaban 3 days (72 hours) before surgery 1
• If renal impairment exists (CrCl 30-50 mL/min), extend discontinuation to 4 days 4
• Resume 48-72 hours after high-bleeding-risk surgery when hemostasis is secure 1

Critical: No bridging anticoagulation is needed or recommended when discontinuing rivaroxaban - bridging increases bleeding risk without reducing thrombotic risk 1, 4

Clopidogrel (Clopilet) 75mg Management

For patients with recent coronary stents:

• Within 12 months of drug-eluting stent or 3 months of bare-metal stent: Dual antiplatelet therapy should NOT be withdrawn - postpone surgery if possible 1
• If surgery is urgent and cannot be delayed: Stop clopidogrel 5 days before surgery while maintaining aspirin if the patient is also on aspirin 1
• However, this patient is on rivaroxaban, not aspirin - the combination of rivaroxaban 2.5mg with clopidogrel suggests peripheral artery disease management 2

For peripheral artery disease after revascularization:

• Clopidogrel is typically used for ≤30 days after endovascular procedures 2
• Stop clopidogrel 5 days before elective surgery 1, 5
• Resume 12-24 hours after surgery when hemostasis is adequate, potentially with a 300mg loading dose 1

Other Medications

Airtel (Telmisartan 40mg) - Angiotensin Receptor Blocker:

• Generally continued perioperatively
• May be held on morning of surgery in some protocols to avoid intraoperative hypotension

Nubera (Nebivolol 5mg) - Beta-blocker:

• Should be continued perioperatively to prevent rebound tachycardia and cardiac events
• Abrupt discontinuation increases cardiovascular risk

Becosules (B-complex vitamins):

• No perioperative concerns, can be continued

Specific Timing Protocol for High-Risk Surgery

Days before surgery:

• Day -5: Stop clopidogrel (last dose) 1, 5
• Day -3: Stop rivaroxaban (last dose) 1
• Continue telmisartan and nebivolol through morning of surgery
• Continue Becosules

Day of surgery:

• Confirm adequate time since last anticoagulant/antiplatelet doses
• Proceed with surgery

After surgery:

• 6-24 hours post-op: Resume rivaroxaban if minor bleeding risk and hemostasis adequate 1, 3
• 48-72 hours post-op: Resume rivaroxaban if high bleeding risk surgery 1
• 12-24 hours post-op: Resume clopidogrel when hemostasis adequate, consider 300mg loading dose 1

Critical Pitfalls to Avoid

• Never use heparin bridging when discontinuing rivaroxaban - this significantly increases bleeding risk without benefit 1, 4
• Do not resume full-dose anticoagulation too early - wait for adequate hemostasis to avoid major bleeding 4
• Avoid operating within critical timeframes after coronary stenting - the risk of stent thrombosis is catastrophic 1
• Recognize that triple therapy (rivaroxaban + clopidogrel + aspirin) significantly increases bleeding risk - this patient appears to be on dual therapy only 2
• Clopidogrel use >30 days with rivaroxaban may increase bleeding risk - consider shorter duration protocols 2

Special Considerations

• If surgery is urgent/emergent: Proceed despite anticoagulation with appropriate hemostatic measures and multidisciplinary consultation 6, 7
• For very high bleeding risk procedures (intracranial neurosurgery, spinal anesthesia): Consider longer interruption periods beyond standard recommendations 1
• Renal function must be assessed - rivaroxaban clearance is significantly affected by renal impairment requiring longer discontinuation 4