How Long to Hold Xarelto Prior to Colonoscopy
For diagnostic colonoscopy, omit the morning dose on the day of the procedure; for therapeutic colonoscopy (with polypectomy or biopsy), hold Xarelto for 3 days (72 hours) before the procedure in patients with normal renal function. 1
Procedure Risk Classification
The type of colonoscopy determines the holding period:
- Low-risk (diagnostic only): Colonoscopy with or without biopsy is considered low bleeding risk 1
- High-risk (therapeutic): Colonoscopy with polypectomy, EMR, or ESD is considered high bleeding risk 1
- Default assumption: Most colonoscopies should be planned as high-risk procedures since polypectomy or biopsy is commonly anticipated 2
Holding Protocol by Renal Function
Normal Renal Function (CrCl ≥50 mL/min)
- Low-risk procedure: Omit only the morning dose on the day of colonoscopy 1
- High-risk procedure: Last dose should be taken 3 days (72 hours) before the procedure 1
- This 3-day interruption allows adequate clearance given rivaroxaban's 8-9 hour half-life and 33% renal elimination 2
Impaired Renal Function (CrCl 30-50 mL/min)
- High-risk procedure: The same 3-day holding period applies for rivaroxaban, unlike dabigatran which requires 5 days 1
- Rivaroxaban clearance decreases moderately with renal impairment, with AUC increasing 1.52-fold in moderate impairment 3
- Verify renal function before determining the holding period, especially in elderly patients where age-related decline can affect clearance 2, 4
Severe Renal Impairment (CrCl 15-30 mL/min)
- Consider extending the holding period beyond 3 days due to 1.64-fold increase in rivaroxaban exposure 3
- Consult hematology if renal function is rapidly deteriorating 1
Important Distinctions from Other DOACs
The guidelines specifically differentiate rivaroxaban from dabigatran:
- Rivaroxaban, apixaban, and edoxaban: 3 days for high-risk procedures regardless of renal function (unless CrCl <30) 1
- Dabigatran only: Requires 5 days when CrCl 30-50 mL/min due to greater renal dependence 1
Bridging Anticoagulation
Do not use bridging therapy when interrupting rivaroxaban for colonoscopy:
- Bridging with LMWH or heparin is unnecessary due to rivaroxaban's rapid offset and onset of action 2
- Bridging increases bleeding risk without reducing thrombotic events 1
- Atrial fibrillation without mechanical heart valves represents low-to-moderate thrombotic risk and does not require bridging during the 3-day interruption 2
Resumption After Colonoscopy
Restart rivaroxaban based on bleeding risk and hemostasis:
- Standard colonoscopy with polypectomy: Resume 24-48 hours after the procedure once adequate hemostasis is confirmed 2
- High-risk interventions (large polypectomy, EMR): Consider waiting 48-72 hours before resuming 2
- Full anticoagulant activity is re-established within 2-4 hours of the first post-procedure dose 1
Key Clinical Pitfalls to Avoid
- Do not use INR or aPTT to guide timing for rivaroxaban, as these tests are unreliable indicators of rivaroxaban anticoagulant activity 1, 2
- Always verify current renal function before determining the holding period, as medications and acute illness can impair renal clearance 2, 5
- Do not assume all colonoscopies are low-risk: Default to the 3-day holding period unless you are certain no polypectomy or biopsy will be performed 2
- Check for interacting medications that inhibit CYP3A4 or P-glycoprotein, as these can prolong rivaroxaban effect 5, 6
Evidence Quality Note
These recommendations are based on the 2021 BSG/ESGE guidelines 1 and supported by the PAUSE trial, which demonstrated low rates of major bleeding and thromboembolism with standardized DOAC interruption protocols 1. The evidence quality is rated as low for the specific recommendations, but the guidelines provide strong recommendations based on pharmacokinetic principles and clinical trial data 1.