Rivaroxaban Hold Duration for Ureteral Stent Placement
For ureteral stent placement, hold rivaroxaban (Xarelto) for 24 hours (1 day) before the procedure in patients with normal renal function, as this is a low to moderate bleeding risk urological intervention.
Bleeding Risk Classification
Ureteral stent placement is classified as a low to moderate bleeding risk procedure based on urological guidelines, which specifically state that ureteroscopy (the procedure used for stent placement) can be performed with continuing oral anticoagulation therapy 1. This classification is critical because it determines the appropriate hold duration for rivaroxaban.
Standard Hold Duration
Hold rivaroxaban for 24 hours (1 day) before the procedure for patients with normal renal function (CrCl >50 mL/min), with the last dose taken on the morning of the day before surgery 2, 3.
No bridging anticoagulation is required during this brief interruption period, as standard interruption periods do not necessitate preoperative heparin bridging except in patients at very high thrombotic risk 3.
The FDA label confirms that rivaroxaban should be stopped at least 24 hours before procedures to reduce bleeding risk 4.
Renal Function Adjustments
Assess creatinine clearance using the Cockcroft-Gault formula before determining hold duration, as rivaroxaban has significant renal elimination 3.
CrCl 30-50 mL/min: Consider extending the discontinuation period to 48 hours due to slower drug clearance 2, 3.
CrCl <30 mL/min: Longer interruption periods (up to 48-72 hours) are necessary due to significantly impaired drug elimination 3.
Additional Risk Factors Requiring Extended Hold
Consider extending the hold period to 48 hours or longer in patients with 3:
- Age >80 years
- Concomitant P-glycoprotein inhibitors (e.g., azole antifungals, protease inhibitors)
- Concomitant CYP3A4 inhibitors
- Any additional risk of drug accumulation
Resumption After Procedure
Resume rivaroxaban at least 24 hours postoperatively once adequate hemostasis is confirmed for this low-moderate bleeding risk procedure 2, 3.
The FDA label emphasizes restarting rivaroxaban after procedures as soon as adequate hemostasis has been established, noting the short time to onset of therapeutic effect 4.
If concerns about hemostasis exist, delay resumption to 48 hours 2.
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.
Not accounting for drug interactions with P-glycoprotein or CYP3A4 inhibitors may result in higher than expected rivaroxaban levels, requiring longer hold periods 3.
Unnecessarily prolonged discontinuation increases thrombotic risk without additional bleeding benefit, particularly given that ureteroscopy is specifically noted as safe to perform with continuing anticoagulation 1, 3.
Avoid routine bridging therapy, as it increases bleeding risk without clear benefit in this clinical scenario 3.