What are the guidelines for managing a patient with pulmonary embolism on Xarelto (rivaroxaban) with multiple malignancies who requires cessation of Xarelto (rivaroxaban) for a biopsy?

From the Guidelines

For a patient with pulmonary embolism on Xarelto (rivaroxaban) who has multiple malignancies and needs to stop anticoagulation for a biopsy, I recommend a bridging strategy using low molecular weight heparin (LMWH). This approach is based on the 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, which recommends LMWH for the initial treatment of established VTE in patients with cancer when creatinine clearance is ≥30 mL/min (grade 1A) 1.

To implement this strategy, stop Xarelto at least 24 hours before the procedure (48 hours if high bleeding risk or renal impairment). Then, switch to therapeutic-dose LMWH (such as enoxaparin 1 mg/kg twice daily) when Xarelto is stopped. Discontinue the LMWH 24 hours before the procedure to minimize the risk of bleeding. After the biopsy, resume LMWH 24 hours post-procedure if hemostasis is adequate, then restart Xarelto once bleeding risk is minimal (typically 24-72 hours post-procedure), overlapping with LMWH for at least 24 hours.

Key considerations for this approach include:

• Cancer-associated thrombosis carries a high recurrence risk, and minimizing the time without anticoagulation is crucial 1.
• LMWH has a shorter half-life than Xarelto, allowing for more precise control around the procedure.
• The presence of malignancy increases both thrombotic and bleeding risks, requiring careful management of this interruption period.
• Consult with the proceduralist about specific timing based on the biopsy site and bleeding risk, as recommended by the guidelines 1.

This bridging strategy with LMWH is preferred because it balances the need to minimize anticoagulant-related bleeding risk during the biopsy with the need to prevent recurrent venous thromboembolism in a patient with malignancy, in line with the guidelines' recommendations for patients with cancer and VTE 1.

From the FDA Drug Label

If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings and Precautions (5. 2)] . XARELTO 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)] .

To stop XARELTO for a biopsy in a patient with pulmonary embolism and malignancy, XARELTO should be stopped at least 24 hours before the procedure. After the biopsy, XARELTO should be restarted as soon as adequate hemostasis has been established 2.

From the Research

Management of Pulmonary Embolism with Malignancy

• In patients with pulmonary embolism (PE) and malignancy, the management of anticoagulation therapy is crucial to prevent recurrence and reduce mortality 3.
• The use of low-molecular-weight heparin (LMWH) is recommended as the initial treatment for PE, due to its efficacy and safety profile compared to unfractionated heparin (UFH) 4, 5.
• Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, or dabigatran are also effective in treating PE and have a lower risk of bleeding compared to heparin combined with a vitamin K antagonist 6.
• In patients with cancer-associated venous thromboembolism (VTE), novel oral anticoagulants (NOACs) can simplify treatment, but require extra caution, especially in patients with gastrointestinal malignancies 3.

Stopping Xeralto for Biopsy

• When stopping Xeralto (rivaroxaban) for a biopsy, it is essential to consider the patient's risk of thromboembolism and bleeding 7.
• The decision to stop anticoagulation therapy should be made on a case-by-case basis, taking into account the patient's individual risk factors and the type of biopsy being performed.
• In general, anticoagulation therapy should be stopped for a minimum of 24 hours before the biopsy, and resumed as soon as possible after the procedure to minimize the risk of thromboembolism 5.

Guidelines for Management

• Current guidelines recommend the use of LMWH or DOACs as the initial treatment for PE, with thrombolysis reserved for patients with massive pulmonary embolism or high-risk PE 6, 5.
• The choice of anticoagulant therapy should be based on the patient's individual risk factors, renal function, and the presence of malignancy 3, 7.
• Regular monitoring of the patient's condition and adjustment of anticoagulation therapy as needed is crucial to prevent recurrence and reduce mortality 4, 6.