Perioperative Management

• Decision making regarding whether rivaroxaban needs to be held depends on type of surgery and balance of bleeding versus thrombosis risk. The duration for withholding is based upon the estimated rivaroxaban half-life times 2 to 3 half-lives for low procedural bleeding risk and 4 to 5 drug half-lives for high procedural bleeding risk. If it is indicated rivaroxaban, should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding, and should be discontinued for at least 24 hours prior to elective surgery or invasive procedures with low bleeding risk or where the bleeding would be non-critical in location easily controlled.
• Rivaroxaban should be discontinued at least 24-72 hours prior to neuraxial intervention (including lumbar puncture). Epidural or spinal hematomas have occurred in patients treated with DOACs who are receiving neuraxial anesthesia or undergoing spinal puncture. Optimal timing between the administration of rivaroxaban and neuraxial procedures is not known.
• In CrCl < 30 mL/minute, for low bleeding risk procedure, discontinue rivaroxaban therapy >36 hours prior. If Cr < 15 mL/min for low bleeding risk procedure consider measuring rivaroxaban anti-Xa level and/or withholding  >48 hours.
• In CrCl < 30 mL/minute, for moderate or high risk procedure, discontinue rivaroxaban therapy >48 hours prior. If Cr < 15 mL/min for moderate or high risk procedure., consider measuring rivaroxaban anti-Xa level and/or withholding  >72 hours.
• In rare cases, in patients with very high risk of thrombosis, bridging with unfractionated heparin may be required to limit the time off anticoagulation.
• Restart rivaroxaban after the procedure as soon as adequate hemostasis has been established and once cleared by the surgeon or interventionalist. If oral medication cannot be taken after the procedure, consider switching to a parenteral anticoagulant.