Perioperative Management of Xarelto (Rivaroxaban)

Discontinuation Guidelines

For patients undergoing low to moderate bleeding risk procedures, the American Society of Anesthesiologists recommends stopping Xarelto 1 day (24 hours) before the procedure, with the last dose taken on the morning of the day before surgery, and no bridging anticoagulation is required during this brief interruption period 1
For high bleeding risk procedures, the American Society of Anesthesiologists suggests stopping Xarelto 2-3 days before the procedure, with timing adjusted based on renal function, and for patients with normal renal function (CrCl >50 mL/min), discontinue 3 days (72 hours) before surgery 2
For very high bleeding risk procedures, such as intracranial neurosurgery or neuraxial anesthesia/puncture, the American Society of Anesthesiologists recommends extending discontinuation up to 5 days before the procedure 2

The American College of Cardiology states that the timing of interruption must account for creatinine clearance using the Cockcroft-Gault formula, as rivaroxaban has significant renal elimination, and for patients with CrCl >50 mL/min, standard 2-3 day discontinuation for high-risk procedures is recommended 2
For patients with CrCl 30-50 mL/min, the American College of Cardiology suggests considering extending the discontinuation period due to slower drug clearance 1
For patients with CrCl <30 mL/min, longer interruption periods are necessary, according to the American College of Cardiology 2

The American Geriatrics Society recommends considering longer interruption periods (up to 5 days) in patients with age >80 years, concomitant P-glycoprotein inhibitors, concomitant CYP3A4 inhibitors, or any additional risk of drug accumulation 2

The American Society of Anesthesiologists states that no preoperative heparin bridging is recommended when standard interruption periods are applied, except in patients at very high thrombotic risk, and unnecessary bridging increases bleeding risk without clear benefit 2
The American College of Cardiology recommends resuming Xarelto as soon as adequate hemostasis has been established, and for low bleeding risk procedures, resume at least 24 hours postoperatively, while for high bleeding risk procedures, resume 48-72 hours postoperatively once adequate hemostasis is confirmed 1

The American Society of Anesthesiologists warns that failing to obtain recent creatinine clearance measurement before determining hold duration can lead to inadequate drug clearance and increased bleeding risk, and not accounting for drug interactions with P-glycoprotein or CYP3A4 inhibitors may result in higher than expected rivaroxaban levels 2
The American College of Cardiology advises against unnecessarily prolonged discontinuation, which increases thrombotic risk without additional bleeding benefit, and never performing neuraxial anesthesia in patients with possible residual rivaroxaban concentration due to insufficient discontinuation time 2

Ureteral stent placement is classified as a low to moderate bleeding risk procedure, and ureteroscopy can be performed with continuing oral anticoagulation therapy, according to urological guidelines 3

The American Urological Association guidelines imply that hold rivaroxaban for 24 hours (1 day) before the procedure for patients with normal renal function, with the last dose taken on the morning of the day before surgery, is based on a low to moderate bleeding risk urological intervention 3

Prophylactic dosing (10 mg once daily) – discontinue rivaroxaban at least 18 hours before performing spinal or epidural anesthesia in patients with normal renal function. 4, 5
Therapeutic dosing (15–20 mg once daily) – discontinue rivaroxaban at least 48 hours before performing spinal or epidural anesthesia in patients with normal renal function. 4, 5
Renal function > 50 mL/min (CrCl) – the standard discontinuation intervals (18 h for prophylaxis, 48 h for therapeutic dosing) are appropriate. 4, 5

Rivaroxaban must not be administered while an epidural or spinal catheter remains in situ. 4, 5

After catheter removal or a single‑shot neuraxial block, rivaroxaban may be restarted no earlier than 6 hours provided that adequate hemostasis has been confirmed. 4, 5

New midline back pain after neuraxial procedures should prompt immediate evaluation for possible spinal hematoma. 4