In a 73-year-old patient with atrial fibrillation on rivaroxaban and normal renal function undergoing total knee arthroplasty, how should perioperative anticoagulation be managed?

Perioperative Rivaroxaban Management for TKA

Hold rivaroxaban for two days pre-procedurally; resume POD1 at dinner time is the recommended approach for this patient with normal renal function undergoing total knee arthroplasty.

Preoperative Discontinuation

For major orthopedic surgery like TKA in patients with normal renal function, rivaroxaban should be stopped 2 days (48 hours) before the procedure, corresponding to approximately 4 half-lives and resulting in minimal (6%) residual anticoagulant effect at the time of surgery 1. This timing is based on rivaroxaban's half-life of 8-9 hours and 33% renal dependence 1.

• The 2-day preoperative hold means the patient skips one dose before surgery, with the last dose taken approximately 48 hours prior to the procedure 1
• This approach applies specifically to patients with normal renal function; those with renal impairment would require extended discontinuation periods of 3 days 1
• No bridging anticoagulation with heparin is required during this brief interruption period, as bridging is only indicated for very high thrombotic risk patients, not routine atrial fibrillation 1

Postoperative Resumption Strategy

Rivaroxaban should be resumed with a reduced-dose approach initially, starting the morning after surgery (POD1) rather than POD0, to minimize bleeding risk while maintaining thromboprophylaxis 1.

• The recommended strategy is to start rivaroxaban 10 mg once daily for the first 2 days postoperatively, then increase to the full therapeutic dose of 20 mg once daily thereafter 1
• This stepwise approach allows for adequate wound hemostasis while providing some anticoagulant coverage 1
• Full therapeutic dosing should not be initiated until 24-72 hours postoperatively once surgical hemostasis is confirmed 1

Key Clinical Considerations

The timing of resumption must balance thrombotic risk from atrial fibrillation against bleeding risk from major orthopedic surgery 1.

• TKA is classified as a major, high bleeding risk procedure that requires careful postoperative anticoagulation management 1
• Starting at dinner time POD1 (approximately 24-36 hours post-surgery) with reduced dosing provides this balance 1
• If prophylactic anticoagulation is used immediately postoperatively (such as LMWH starting 6 hours after surgery), ensure a 12-hour gap before initiating therapeutic-dose rivaroxaban to avoid overlap 1

Common Pitfalls to Avoid

• Do not resume full-dose rivaroxaban on POD0: This significantly increases bleeding risk without corresponding thrombotic benefit 1
• Avoid holding rivaroxaban for only 1 day preoperatively: This provides insufficient drug clearance (only 2 half-lives) for major surgery 1
• Do not hold for 3 days in patients with normal renal function: This is unnecessarily prolonged and increases thrombotic risk without additional bleeding benefit 1
• Monitor renal function postoperatively: Acute kidney injury from surgery can affect rivaroxaban clearance and may require dose adjustment 1, 2