From the Guidelines
It is recommended to stop Xarelto for 48 hours in this 73-year-old male patient with epistaxis who takes the medication for atrial fibrillation. The patient's elevated PROTIME of 23.9 seconds and INR of 2.1 indicate significant anticoagulation effect, which is contributing to the nosebleed. Stopping Xarelto for 48 hours allows the drug to be cleared from the system, as it has a half-life of approximately 5-9 hours in elderly patients. This temporary discontinuation helps control the epistaxis by allowing normal clotting mechanisms to resume. According to the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1, for patients with AF and normal renal function undergoing elective procedures during which hemostatic control is essential, discontinuation of anticoagulants for ≥48 hours is suggested.
Key Considerations
- The patient should be monitored for signs of thromboembolism during the 48-hour period, though short-term interruption generally carries acceptable risk.
- Once bleeding is controlled and hemostasis achieved, Xarelto can be restarted, typically at the same previous dose.
- For severe or persistent bleeding, reversal agents like andexanet alfa might be considered.
- The patient should avoid activities that increase bleeding risk and apply direct pressure to control the nosebleed in the meantime.
Management
- Monitoring activated partial thromboplastin time for dabigatran and prothrombin time for apixaban and rivaroxaban may be helpful; a level consistent with control levels suggests a low serum concentration of the anticoagulant 1.
- The management of postoperative AF is similar to that for other forms of new-onset AF, except that the potential benefit of anticoagulation needs to be balanced against the risk of postoperative bleeding 1.
From the Research
Management of Epistaxis in Patients on Anticoagulation Therapy
- The management of epistaxis in patients on anticoagulation therapy, such as Xarelto (rivaroxaban), is complex and requires careful consideration of the patient's underlying condition and the risk of bleeding 2.
- Studies have shown that patients on direct oral anticoagulants (DOACs) such as rivaroxaban have shorter hospital stays and fewer hospital admissions compared to those on traditional vitamin K antagonists such as phenprocoumon 3, 4.
- The decision to stop Xarelto for 48 hours in a patient with epistaxis may be based on the need to reduce the risk of further bleeding, as the patient's PROTIME and INR levels are elevated, indicating an increased risk of bleeding 5, 6.
- However, it is essential to weigh the risks and benefits of stopping anticoagulation therapy, as it may increase the risk of thromboembolic events, particularly in patients with atrial fibrillation 3, 4.
Considerations for Stopping Xarelto
- The patient's elevated PROTIME and INR levels indicate an increased risk of bleeding, which may be exacerbated by continued anticoagulation therapy 5, 6.
- Stopping Xarelto for 48 hours may allow for the reduction of the patient's bleeding risk, but it is crucial to consider the patient's underlying condition and the potential risks of stopping anticoagulation therapy 3, 4.
- The decision to stop Xarelto should be made in consultation with the patient's healthcare team, taking into account the patient's individual risk factors and medical history 2, 5.
Recommendations for Management
- Patients on DOACs such as rivaroxaban should be closely monitored for signs of bleeding, and the decision to stop anticoagulation therapy should be made on a case-by-case basis 3, 4.
- The use of reversal agents, such as idarucizumab for dabigatran, may be considered in patients with severe bleeding, but their effectiveness and safety in patients on rivaroxaban are not well established 5.
- Further research is needed to determine the optimal management of epistaxis in patients on anticoagulation therapy, including the use of DOACs and reversal agents 2, 5.