Summary of periprocedural management of anticoagulants and antiplatelet medications for interventional pain procedures

Drug	When to stop			When to restart
Drug	High-risk procedures	Intermediate-risk procedures	Low-risk procedures	When to restart
ASA and ASA combinations	Primary prophylaxis: 6 days Secondary prophylaxis: Shared assessment and risk stratification	Shared assessment and risk stratification*^¶	No	24 hours
NSAIDs	5 half-lives	No^Δ	No	24 hours
Diclofenac	1 day
Ketorolac	1 day
Ibuprofen	1 day
Etodolac	2 days
Indomethacin	2 days
Naproxen	4 days
Meloxicam	4 days
Nabumetone	6 days
Oxaprozin	10 days
Piroxicam	10 days
Phosphodiesterase inhibitors
Cilostazol	2 days	No	No	24 hours
Dipyridamole	2 days	No	No
ASA combinations	Follow ASA recommendations	Shared assessment and risk stratification*
Anticoagulants
Coumadin	5 days, normal INR	5 days, normal INR	No; shared assessment and risk stratification*	6 hours
Acenocoumarol	3 days, normal INR	3 days, normal INR	No; shared assessment and risk stratification*	24 hours
IV heparin	6 hours	6 hours	6 hours	2 hours^◊
Subcutaneous heparin, BID, and TID	24 hours	6 hours	6 hours	2 hours (low-/intermediate-risk procedures) 6 hours (high-risk procedures
LMWH: Enoxaparin (prophylactic)	12 hours	12 hours	12 hours	4 hours (low-risk procedures) 12 to 24 hours (medium-/high-risk pain procedures)
LMWH: Enoxaparin (therapeutic)	24 hours	24 hours	24 hours	4 hours (low-risk procedures) 12 to 24 hours (intermediate-/high-risk pain procedures)
LMWH: Dalteparin	24 hours	24 hours	24 hours	4 hours (low-risk procedures) 12 to 24 hours (intermediate-/high-risk pain procedures)
Fibrinolytic agents	48 hours	48 hours	48 hours	N/A^§
Fondaparinux	4 days	4 days	Shared assessment and risk stratification	6 hours (low-/intermediate-risk procedures) 24 hours (high-risk procedures)
P2Y12 inhibitors
Clopidogrel	7 days	7 days	No; shared assessment and risk stratification	12 to 24 hours*
Prasugrel	7 to 10 days	7 to 10 days	No; shared assessment and risk stratification	24 hours
Ticagrelor	5 days	5 days	No; shared assessment and risk stratification	24 hours
Cangrelor	3 hours	3 hours	Shared assessment and risk stratification	24 hours
NOACs
Dabigatran	4 days 5 to 6 days (impaired renal function)	4 days 5 to 6 days (impaired renal function)	Shared assessment and risk stratification*	24 hours
Rivaroxaban	3 days	3 days	Shared assessment and risk stratification*	24 hours
Apixaban	3 days	3 days	Shared assessment and risk stratification*	24 hours
Edoxaban	3 days	3 days	Shared assessment and risk stratification*	24 hours
GP IIb/IIIa inhibitors
Abciximab	2 to 5 days	2 to 5 days	2 to 5 days	8 to 12 hours
Eptifibatide	8 to 24 hours	8 to 24 hours	8 to 24 hours	8 to 12 hours
Tirofiban	8 to 24 hours	8 to 24 hours	8 to 24 hours	8 to 12 hours
Antidepressants and SRIs	Individualized^¥	No	No	Individualized^¥

ASA: aspirin; INR: international normalized ratio; IV: intravenous; BID: two times per day; TID: three times per day; LMWH: low-molecular-weight heparin; N/A: not applicable; NOACS: novel oral anticoagulants; GP: glycoprotein; SRIs: serotonin reuptake inhibitors.
* Refer to detailed text in the corresponding section of the source article.
¶ Consideration should be given to the discontinuation of ASA for certain intermediate-risk procedures including interlaminar cervical ESIs and stellate ganglion blocks where specific anatomical configurations may increase the risk and consequences of procedural bleeding.
Δ Consideration should be given to the discontinuation of NSAIDs for certain intermediate-risk procedures including interlaminar cervical ESIs and stellate ganglion blocks where specific anatomical configurations may increase the risk and consequences of procedural bleeding (refer to the section entitled "Anatomical Considerations for the Development of a Hematoma in Spinal and Non‐spinal Areas" in the source article).
◊ If a moderate- or high-risk procedure was bloody, then a 24-hour interval should be observed.
§ After an intervention, the usual daily dose (75 mg) of clopidogrel can be started 12 hours later. If a loading dose of clopidogrel is given, then the interval should be 24 hours.
¥ For more information, refer to the section entitled "SRIs and Anticoagulants" and table 6 in the source article, as well as the UpToDate content on the pharmacology and side effects of selective serotonin reuptake inhibitors.

Reproduced with permission from: Narouze S, Benzon HT, Provenzano DA, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulation medications (second edition): Guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2018; 43(3):225-262. Copyright © 2018 BMJ Publishing Group Ltd.

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Summary of periprocedural management of anticoagulants and antiplatelet medications for interventional pain procedures