What is the recommended protocol for transitioning a patient from a heparin (Heparin Sodium) drip to Xarelto (Rivaroxaban)?

Transitioning from Heparin Drip to Xarelto (Rivaroxaban)

Stop the heparin infusion and start rivaroxaban 15 mg twice daily immediately at the time the next heparin dose would have been due—no bridging or overlap is required, and no INR monitoring is necessary. 1

Direct Transition Protocol

For patients currently on unfractionated heparin (UFH) continuous infusion:

• Discontinue the heparin infusion 1
• Start rivaroxaban 15 mg orally twice daily with food at the exact time the next heparin dose would have been administered 1
• Continue 15 mg twice daily for 21 days, then reduce to 20 mg once daily 2
• No overlap period is needed—rivaroxaban has rapid onset of therapeutic effect 1

This approach is explicitly outlined in the FDA labeling for rivaroxaban and supported by multiple guidelines. The EINSTEIN trials established this single-drug regimen as equally effective and safer than traditional heparin-to-warfarin bridging 2.

Key Dosing Details

Initial phase (Days 1-21):

• 15 mg orally twice daily (every 12 hours) with food 2, 1
• Food administration is mandatory for the 15 mg dose to ensure adequate absorption 1

Maintenance phase (Day 22 onward):

• 20 mg once daily with food 2

Critical Contraindications and Cautions

Avoid rivaroxaban or use extreme caution in:

• Creatinine clearance <30 mL/min—rivaroxaban is contraindicated 2, 1
• Moderate-to-severe hepatic disease (Child-Pugh Class B or C) 2
• Active gastric or gastroesophageal lesions—significantly increased bleeding risk with rivaroxaban compared to LMWH 2
• Pregnancy or nursing patients 2

For patients with gastric/gastroesophageal tumors specifically, LMWH is strongly preferred over any DOAC due to hemorrhage risk 2.

Why No Bridging is Needed

The traditional heparin-warfarin overlap is NOT required with rivaroxaban because:

• Rivaroxaban achieves therapeutic anticoagulation within 2-4 hours of the first dose 1
• The EINSTEIN trials demonstrated that immediate rivaroxaban monotherapy (without parenteral bridging) was as effective as 5-10 days of LMWH followed by warfarin 2
• Bridging with heparins during DOAC transition increases bleeding risk without reducing thrombotic events 2

Multiple guidelines explicitly state that preoperative or periprocedural bridging with UFH or LMWH is not recommended when transitioning to or from DOACs 2.

Special Populations

For heparin-induced thrombocytopenia (HIT):

If transitioning a patient with confirmed or suspected HIT, rivaroxaban is an acceptable option in clinically stable patients at average bleeding risk 2. Use the same dosing: 15 mg twice daily for 3 weeks, then 20 mg once daily 2. However, in life- or limb-threatening thromboembolism (massive PE, venous limb gangrene), a parenteral non-heparin anticoagulant may be preferred initially 2.

For patients unable to swallow tablets:

Rivaroxaban 15 mg tablets may be crushed and mixed with applesauce immediately prior to administration, but must be followed immediately by food 1.

Timing Considerations

If anticoagulation must be interrupted for procedures:

• Stop rivaroxaban at least 24 hours before high-bleeding-risk procedures 1
• Restart as soon as adequate hemostasis is established (minimum 6 hours post-procedure) 2
• The rapid onset means therapeutic effect returns quickly 1

Common Pitfalls to Avoid

1. Do NOT overlap heparin and rivaroxaban—this increases bleeding without benefit 2
2. Do NOT check aPTT or INR to guide transition—these tests are not useful for rivaroxaban monitoring 1
3. Do NOT forget food with the 15 mg dose—absorption is significantly reduced without food 1
4. Do NOT use standard VTE dosing in early-phase acute VTE requiring high-intensity anticoagulation—discuss with multidisciplinary team 2
5. Do NOT transition to rivaroxaban if the patient has been on heparin <5 days AND has cancer with gastric/GE involvement—use LMWH instead 2

Advantages Over Traditional Bridging

The British Thoracic Society found that rivaroxaban significantly reduced length of hospital stay compared to enoxaparin/warfarin bridging: 45% of rivaroxaban patients had stays ≤5 days versus only 33% with traditional therapy 2. This single-drug approach eliminates the complexity of overlapping parenteral and oral anticoagulation while maintaining equivalent efficacy and superior safety profiles 2.