Is it okay to stop taking Xarelto (rivaroxaban) for 3 days prior to a back injection?

Stopping Xarelto for Back Injection

Yes, stopping Xarelto for 3 days prior to a back injection is appropriate and aligns with current guidelines, as back injections involving neuraxial procedures are classified as very high bleeding risk procedures requiring complete drug clearance. 1, 2

Classification of Back Injections

• Back injections involving epidural or spinal approaches are categorized as very high hemorrhagic risk procedures because spinal/epidural bleeding can cause permanent neurological damage, and surgical hemostasis cannot be performed safely in this anatomical location. 1, 3

• Guidelines explicitly state that neuraxial anesthesia/puncture requires a longer interruption time of direct oral anticoagulants (DOAs) prior to the planned procedure—up to 5 days for rivaroxaban (Xarelto) in the absence of renal failure. 1

Recommended Hold Duration

• For patients with normal or mildly impaired renal function (CrCl >50 mL/min), stop Xarelto 3 days (72 hours) before the back injection, which corresponds to the last dose being taken on the morning 3 days prior to the procedure. 1, 2

• For patients with moderate renal impairment (CrCl 30-50 mL/min), extend the discontinuation period to 4-5 days due to slower drug clearance and prolonged half-life. 1

• The FDA label states that Xarelto should be stopped at least 24 hours before procedures to reduce bleeding risk, but this applies only to low-risk procedures—neuraxial procedures require substantially longer interruption. 4

Critical Pre-Procedure Requirements

• Obtain a recent creatinine clearance measurement using the Cockcroft-Gault formula before determining the exact hold duration, as rivaroxaban has significant renal elimination (approximately 33% unchanged in urine). 1, 2

• Check for concomitant medications that may prolong rivaroxaban levels, including P-glycoprotein inhibitors (e.g., ketoconazole, erythromycin, ritonavir) or CYP3A4 inhibitors, which may require extending the hold period up to 5 days. 1, 2

• Consider extending discontinuation to 5 days in patients over 80 years of age, as advanced age affects drug clearance. 1, 2

Bridging Anticoagulation

• Do not use preoperative heparin bridging (unfractionated heparin or low-molecular-weight heparin) when discontinuing Xarelto for this procedure. 1, 2

• Bridging therapy increases bleeding risk without clear benefit and has been associated with higher complication rates in patients undergoing invasive procedures. 1, 2

Resumption After Procedure

• Resume Xarelto 48-72 hours after the back injection, provided adequate hemostasis has been established and there is no ongoing bleeding or surgical contraindication. 1, 2

• The FDA label indicates that Xarelto should be restarted as soon as adequate hemostasis has been established, noting the rapid onset of therapeutic effect. 4

Critical Safety Warning

• Never perform neuraxial anesthesia or spinal puncture in patients with possible residual Xarelto concentration due to insufficient discontinuation time. 1, 2

• This is the single most important pitfall to avoid, as inadequate drug clearance during neuraxial procedures can result in spinal hematoma with permanent neurological sequelae. 1

• Guidelines emphasize this warning particularly for patients on rivaroxaban over 80 years of age or with renal impairment. 1

Practical Algorithm

1. Verify renal function (calculate CrCl using Cockcroft-Gault formula) 1, 2
2. Review medication list for P-glycoprotein or CYP3A4 inhibitors 1, 2
3. Determine hold duration:
   • CrCl >50 mL/min: Stop 3 days before procedure 1, 2
   • CrCl 30-50 mL/min: Stop 4-5 days before procedure 1
   • Age >80 years or drug interactions: Consider 5-day hold 1, 2
4. No bridging anticoagulation 1, 2
5. Resume 48-72 hours post-procedure once hemostasis confirmed 1, 2