Perioperative Management of Rivaroxaban for Appendectomy

Preoperative Management

The American College of Cardiology recommends suspending rivaroxaban 48 hours before appendectomy to minimize the risk of bleeding, which corresponds to approximately 4 half-lives and results in a minimal residual anticoagulant effect (6%) at the time of surgery 1, 2
For patients with normal renal function, 48 hours of suspension is sufficient, based on the elimination half-life of rivaroxaban of 8-9 hours and its dependence on renal clearance of 33% 1, 2
The ROCKET AF trial used this 2-day suspension protocol before elective surgery with safe results 3

The American College of Cardiology recommends restarting rivaroxaban 48-72 hours after appendectomy (2-3 days postoperative) once adequate hemostasis has been established 1, 2
For patients with high thromboembolic risk, consider using a reduced dose of rivaroxaban (10 mg once daily) for the first 2 days after surgery, followed by the full dose of 20 mg once daily 1, 2
Postoperative factors such as intestinal dysmotility after abdominal surgery may affect drug absorption, and the risk of bleeding from the procedure determines post-procedure management, while the patient's thromboembolic risk drives the aggressiveness of the antithrombotic strategy 2, 4

The American College of Cardiology does not recommend bridging anticoagulation with unfractionated heparin or low-molecular-weight heparin during preoperative suspension of rivaroxaban 4
Although routine monitoring is not required, measuring prothrombin time (PT) with reagents sensitive to rivaroxaban may be useful to confirm low levels before surgery; a level close to control suggests a low serum concentration 3