When is bridging anticoagulation required when Xarelto (Rivaroxaban) is held 48 hours pre-colonoscopy?

From the Guidelines

Bridging anticoagulation is typically not needed when Xarelto (rivaroxaban) is held for 48 hours prior to a colonoscopy in most patients. For the majority of patients on Xarelto, simply discontinuing the medication 48 hours before the procedure and resuming it once hemostasis is achieved (usually 24-48 hours after the procedure) is sufficient. However, bridging may be considered in patients at very high thrombotic risk, such as those with recent venous thromboembolism (within the previous 3 months), mechanical heart valves (particularly mitral position), or recent stroke/TIA (within the previous 3 months) 1. In these high-risk cases, a short-acting anticoagulant like unfractionated heparin or low molecular weight heparin might be used during the perioperative period when Xarelto is held. The decision to bridge should be individualized based on balancing the patient's thrombotic risk against their bleeding risk. Xarelto has a relatively short half-life (5-9 hours in healthy adults, 11-13 hours in elderly), which allows for relatively quick clearance from the system, making bridging unnecessary for most patients when the 48-hour discontinuation protocol is followed.

Some key points to consider when deciding on bridging anticoagulation include:

• The patient's thrombotic risk, including factors such as recent venous thromboembolism, mechanical heart valves, or recent stroke/TIA
• The patient's bleeding risk, including factors such as age, comorbidities, and concomitant medications
• The type of procedure being performed, including the risk of bleeding and the need for anticoagulation
• The patient's renal function, as Xarelto is contraindicated in patients with severe renal impairment

According to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines, bridging anticoagulation is not recommended for most patients undergoing colonoscopy, except for those at high thrombotic risk 1. The guidelines also recommend individualizing the decision to bridge based on the patient's specific risk factors and clinical circumstances. A study published in the journal Gut found that bridging anticoagulation with heparin increased the risk of post-procedure bleeding without reducing the risk of thromboembolic events 1.

In terms of specific patient populations, those with a history of venous thromboembolism within 3 months of commencing anticoagulant therapy are at high risk of recurrent thrombosis if anticoagulation is interrupted, and bridging may be considered in these cases 1. However, for most patients with thrombophilia syndromes, bridging therapy is not required 1.

Overall, the decision to bridge anticoagulation should be made on a case-by-case basis, taking into account the patient's individual risk factors and clinical circumstances.

From the FDA Drug Label

2.4 Discontinuation for Surgery and other Interventions 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 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 If oral medication cannot be taken during or after surgical intervention, consider administering a parenteral anticoagulant.

The patient needs bridging anticoagulation when Xarelto is held 48 hours prior to a colonoscopy if the patient has a high risk of thrombotic events, such as those with:

• Mechanical heart valves
• Atrial fibrillation with a high stroke risk
• Venous thromboembolism (VTE) with a high risk of recurrence In these cases, parenteral anticoagulation should be considered to bridge the gap until Xarelto can be restarted after the procedure. However, the provided drug label does not explicitly state when bridging anticoagulation is needed for a colonoscopy. Therefore, the decision to use bridging anticoagulation should be made on a case-by-case basis, considering the individual patient's risk factors and medical history 2.

From the Research

Bridging Anticoagulation with Xarelto

When Xarelto is held 48 hours prior to a colonoscopy, the need for bridging anticoagulation depends on various factors.

• The decision to use bridging anticoagulation is typically based on the patient's risk of thromboembolism and bleeding 3.
• Studies have shown that bridging anticoagulation with low-molecular-weight heparin (LMWH) can be effective in preventing thromboembolic events 3.
• However, the use of LMWH can also increase the risk of bleeding, particularly in patients who receive therapeutic-dose LMWH 3.

Patient-Specific Factors

The decision to use bridging anticoagulation should take into account patient-specific factors, such as:

• The patient's risk of thromboembolism, which can be assessed using clinical prediction rules 4.
• The patient's risk of bleeding, which can be assessed using clinical prediction rules 4.
• The patient's renal function, as some anticoagulants may require dose adjustment in patients with renal impairment 4.

Alternative Anticoagulants

In some cases, alternative anticoagulants such as fondaparinux or rivaroxaban may be used for bridging anticoagulation.

• Fondaparinux has been shown to be effective in preventing thromboembolic events, but its use is limited by its potential to cause bleeding [(5,6)].
• Rivaroxaban is an oral, direct Factor Xa inhibitor that has been shown to be effective in preventing thromboembolic events, and may be a suitable alternative to LMWH 7.