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AI-Generated response:

How soon should rivaroxaban be discontinued prior to elective surgery?

Answer generated on June 4, 2024

The AI-generated responses are for illustration purposes only and should not be used for medical purposes.

Rivaroxaban should be discontinued at least 24 hours before elective surgery to reduce the risk of bleeding.[1-2]

  • The timing of discontinuation is crucial to minimize bleeding risks while considering the urgency of the surgical procedure.

  • Rivaroxaban should be restarted as soon as adequate hemostasis has been established post-surgery.

  • If oral intake is not feasible post-surgery, consider using a parenteral anticoagulant.

  • For procedures involving neuraxial anesthesia or lumbar puncture, ensure that rivaroxaban is stopped following the specific timelines related to the half-life of the drug to reduce the risk of spinal or epidural hematoma.[1]

  • Monitor patients closely for signs of neurological impairment if neuraxial interventions are employed while the patient is on rivaroxaban or shortly after its discontinuation.[1]

Additional info

When planning the discontinuation of rivaroxaban before elective surgery, it's important to balance the risk of thrombosis due to stopping anticoagulation against the risk of bleeding if anticoagulation is continued. The decision to delay elective procedures until 24 hours after the last dose of rivaroxaban has been administered should consider these risks. Additionally, the pharmacokinetics of rivaroxaban, such as its half-life and the time to reach a low anticoagulant effect, are crucial in timing the discontinuation appropriately, especially in patients with varying ages and renal functions as these factors can affect drug clearance.[1-2] After the procedure, the timing of rivaroxaban resumption should be carefully planned to ensure that hemostasis is adequate, thereby minimizing the risk of postoperative bleeding while also protecting against thromboembolic events.[2]

References

Reference 1

1.

Elsevier ClinicalKey Drug Monograph

Content last updated: May 3, 2024.

Contraindications And Precautions If epidural anesthesia, lumbar puncture, or spinal anesthesia is employed, monitor patients frequently for signs and symptoms of neurological impairment such as midline back pain, sensory and motor deficits (numbness, tingling, or weakness in lower limbs), bowel and/or bladder dysfunction. Instruct patients to immediately report if they experience any of the above signs or symptoms. If signs or symptoms of spinal hematoma are suspected, initiate urgent diagnosis and treatment, including consideration for spinal cord decompression even though such treatment may not prevent or reverse neurological sequelae. If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, discontinue rivaroxaban at least 24 hours before the procedure. When deciding whether a procedure should be delayed until 24 hours after the last rivaroxaban dose was administered, weigh the increased risk of bleeding against the urgency of the surgical procedure or intervention. Following the surgical procedure or intervention, restart rivaroxaban as soon as hemostasis has been established. If oral therapy is not possible, consider administration of a parenteral anticoagulant.

Contraindications And Precautions The use of other procoagulant reversal agents like activated prothrombin complex concentrate (APCC) or recombinant factor VIIa (rFVIIa) has not been evaluated. Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis. Epidural or spinal hematomas that may result in long-term or permanent paralysis may occur in patients who are anticoagulated and are receiving neuraxial anesthesia or undergoing spinal puncture. Consider these risks when scheduling patients for spinal procedures. To reduce the potential risk of bleeding, it is best to perform the placement or removal of an epidural catheter or lumbar puncture when the anticoagulant effect of rivaroxaban is low based on the pharmacokinetic profile of rivaroxaban. The exact timing to reach a sufficiently low anticoagulant effect in each patient is not known. Do not remove an epidural or intrathecal catheter before 2 half-lives have elapsed (i.e., 18 hours in patients aged 20 to 45 years and 26 hours in patients aged 60 to 76 years) after the last administration of rivaroxaban, and do not administer the next rivaroxaban dose earlier than 6 hours after the catheter removal. Delay rivaroxaban administration for 24 hours if a traumatic puncture occurs. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include use of indwelling epidural catheters; concomitant use of other drugs that affect hemostasis such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants; a history of traumatic or repeated epidural or spinal punctures; and a history of spinal deformity or spinal surgery.

Reference 2

2.

Food and Drug Administration (DailyMed).

Publish date: February 5, 2023.

Dosage And Administration After 2 days of co-administration, an INR should be obtained prior to the next scheduled dose of Xarelto (rivaroxaban). Co-administration of Xarelto (rivaroxaban) and warfarin is advised to continue until the INR is ≥ 2.0. Once Xarelto (rivaroxaban) is discontinued, INR testing may be done reliably 24 hours after the last dose. Switching from Xarelto (rivaroxaban) to Anticoagulants other than Warfarin - For adult and pediatric patients currently taking Xarelto (rivaroxaban) and transitioning to an anticoagulant with rapid onset, discontinue Xarelto (rivaroxaban) and give the first dose of the other anticoagulant (oral or parenteral) at the time that the next Xarelto (rivaroxaban) dose would have been taken [see Drug Interactions (7.4) ]. Switching from Anticoagulants other than Warfarin to Xarelto (rivaroxaban) - For adult and pediatric patients currently receiving an anticoagulant other than warfarin, start Xarelto (rivaroxaban) 0 to 2 hours prior to the next scheduled administration of the drug (e.g., low molecular weight heparin or non-warfarin oral anticoagulant) and omit administration of the other anticoagulant. For unfractionated heparin being administered by continuous infusion, stop the infusion and start Xarelto (rivaroxaban) at the same time. 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 (rivaroxaban) should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings and Precautions (5.2) ]. In deciding whether a procedure should be delayed until 24 hours after the last dose of Xarelto (rivaroxaban), the increased risk of bleeding should be weighed against the urgency of intervention.

Dosage And Administration In deciding whether a procedure should be delayed until 24 hours after the last dose of Xarelto (rivaroxaban), the increased risk of bleeding should be weighed against the urgency of intervention. Xarelto (rivaroxaban) 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 [see Warnings and Precautions (5.1) ]. If oral medication cannot be taken during or after surgical intervention, consider administering a parenteral anticoagulant. 2.5 Missed Dose Adults For patients receiving 2.5 mg twice daily: if a dose is missed, the patient should take a single 2.5 mg Xarelto (rivaroxaban) dose as recommended at the next scheduled time. For patients receiving 15 mg twice daily: The patient should take Xarelto (rivaroxaban) immediately to ensure intake of 30 mg Xarelto (rivaroxaban) per day. Two 15 mg tablets may be taken at once. For patients receiving 20 mg, 15 mg or 10 mg once daily: The patient should take the missed Xarelto (rivaroxaban) dose immediately. The dose should not be doubled within the same day to make up for a missed dose. Pediatric Patients If Xarelto (rivaroxaban) is taken once a day, the patient should take the missed dose as soon as possible once it is noticed, but only on the same day. If this is not possible, the patient should skip the dose and continue with the next dose as prescribed. The patient should not take two doses to make up for a missed dose. If Xarelto (rivaroxaban) is taken two times a day, the patient should take the missed morning dose as soon as possible once it is noticed. A missed morning dose may be taken together with the evening dose. A missed evening dose can only be taken in the same evening. If Xarelto (rivaroxaban) is taken three times a day, if a dose is missed, the patient should skip the missed dose and go back to the regular dosing schedule at the usual time without compensating for the missed dose. On the following day, the patient should continue with their regular regimen.

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