Answer: Rivaroxaban Therapy Before, During, and After a Colonoscopy
Correct answer: C. Pause treatment for at least 24 hours before the procedure
For the PAUSE study,1 researchers studied a perioperative plan for patients with atrial fibrillation taking direct oral anticoagulants (DOACs). Based on the bleeding risk of the procedure (categorized as high risk or low risk), a DOAC-specific algorithm was developed to guide the timing of medication discontinuation in relation to the procedure; procedures with a higher risk for bleeding required more time off the DOAC prior to the procedure. More than 3000 patients were enrolled. Following the study-derived algorithm had led to 30-day postoperative bleeding rates of less than 2% and stroke rates of less than 1%, suggesting the study-derived algorithm is both safe and effective at mitigating periprocedural DOAC-related complications.
Colonoscopy procedures were classified as low risk based on the PAUSE study algorithm, which would suggest that the presented patient should hold her rivaroxaban for 24 hours prior to the procedure (in other words, omit only a single dose). However, in this specific instance given the patient’s renal function (calculated creatinine clearance of 50 mL/min), additional caution is warranted. The package insert for rivaroxaban suggests lowing the dose to 15 mg daily if the creatinine clearance is less than 50 mL/min.
Since the patient is on the border of needing a dose adjustment, we would be worried that the medication levels would persist at higher levels for longer given she remains on the 20-mg dose, which could increase the chances for intraoperative bleeding. Additionally, some gastrointestinal surgeons may be uncomfortable with only a 24-hour hold before performing the procedure. Further, as her CHA2DS2-VASc score is 4 (3 if not considering sex), her overall risk is low to moderate. The BRIDGE study2 showed that warfarin interruption, without a bridge, was safer and as effective as bridging in patients with atrial fibrillation who require therapy interruption for procedures.
Therefore, the presented patient should be counseled to take her last dose of rivaroxaban 3 days prior to the procedure and hold the following 2 doses (2 days prior and 1 day prior) heading into the procedure. She should resume her rivaroxaban at least 6 hours after the procedure, but this will be left to the discretion of the gastroenterology team to determine what level of hemostasis was achieved during the procedure; if inadequate, she could be asked to hold the rivaroxaban for an additional 1 to 2 days before resuming.
References
1. Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019;179(11):1469-1478. https://doi.org/10.1001/jamainternmed.2019.2431
2. Douketis JD, Spyropoulos AC, Kaatz S, et al; BRIDGE investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. NEJM. 2015;373(9):823-833. https://doi.org/10.1056/nejmoa1501035