Timing of neuraxial anesthesia during antithrombotic therapy

Anticoagulant	Interval from last dose to placement/removal	Interval from placement/removal to next dose	Notes
Direct oral factor Xa inhibitors	It is acceptable to perform neuraxial block or remove a neuraxial catheter if a residual DOAC plasma level is <30 ng/mL or a residual anti-factor Xa activity plasma level is ≤0.1 IU/mL^*
Rivaroxaban	High dose (15 mg once or twice daily or 20 mg once daily):		FDA: Remove catheter ≥18 hours after the last dose in patients 20 to 45 years of age, ≥26 hours in patients 60 to 75 years of age. Administer the next dose ≥6 hours after catheter removal. Administer first dose ≥24 hours after traumatic puncture.
	72 hours	24 hours Remove catheter prior to first postoperative dose If unanticipated administration occurs with catheter in place, withhold further doses and wait for 72 hours to remove catheter, or measure rivaroxaban plasma level or anti-factor Xa level
	Low dose (2.5 mg twice daily or 10 mg once daily):
	24 hours 30 hours if CrCl <30 mL/minute	6 hours Remove catheter prior to first postoperative dose If unanticipated administration occurs with catheter in place, withhold further doses and wait 24 hours (30 hours if CrCl is <30 mL/minute or measure rivaroxaban plasma level or anti-factor Xa level)
Apixaban	High dose (5 or 10 mg twice daily; 2.5 mg twice daily in patients with ≥2 of: age 80 years, weight <60 kg, serum creatinine ≥1.5 mg/dL):		FDA: Remove catheter ≥24 hours after the last dose. Administer the next dose ≥5 hours after catheter removal. Administer first postoperative dose ≥48 hours after traumatic puncture.
	72 hours or measure apixaban plasma level or anti-factor Xa level	24 hours Remove catheter prior to first postoperative dose If unanticipated administration occurs with catheter in place, withhold further doses and wait 72 hours or measure apixaban plasma level or anti-factor Xa level
	Low dose (2.5 mg twice daily):
	36 hours or measure apixaban plasma level or anti-factor Xa level	6 hours Remove catheter prior to first postoperative dose If unanticipated administration occurs with catheter in place, withhold further doses and wait 36 hours or measure apixaban plasma level or anti-factor Xa level
Edoxaban	72 hours or measure edoxaban plasma level or anti-factor Xa level	24 hours Remove catheter prior to first postoperative dose If unanticipated administration occurs with catheter in place, withhold further doses and wait for 72 hours to remove catheter, or measure edoxaban plasma level or anti-factor Xa level	FDA: Remove catheter at least 12 hours after last dose. Administer next dose ≥2 hours after catheter removal.
Heparin (unfractionated)	When heparin given for >4 days, check platelets (risk of HIT) prior to insertion or removal
Intravenous	4 to 6 hours and verify normal aPTT	1 hour	Bloody/difficult needle placement may increase bleeding risk with subsequent IV heparin; use with caution.
Subcutaneous low dose thromboprophylaxis (5000 units subcutaneously twice per day or three times per day)	4 to 6 hours or verify normal aPTT
Subcutaneous higher dose thromboprophylaxis (7500 to 10,000 units subcutaneously twice per day, total daily dose ≤20,000 units)	12 hours and verify normal aPTT
Subcutaneous therapeutic (individual dose >10,000 units subcutaneously or total daily dose >20,000 units subcutaneously)	24 hours and verify normal aPTT
Low molecular weight heparin (LMWH)	Delay LMWH 24 hours after traumatic placement. Anti-factor Xa level is not predictive of the risk of bleeding and should not routinely be measured. If measured, neuraxial anesthesia is appropriate if anti-factor Xa level is ≤0.1 IU/mL.^* Do not use with antiplatelet or oral anticoagulant medications as this increases risk of spinal hematoma. Assess platelet count prior to NA for patients who have received LMWH >4 days; SOAP consensus statement and European guidelines do not recommend platelet count.
High dose (subcutaneous): Enoxaparin 1 mg/kg every 12 hours Enoxaparin 1.5 mg/kg daily Dalteparin 120 units/kg every 12 hours Dalteparin 200 units/kg daily Tinzaparin 175 units/kg daily	≥24 hours If <24 hours, anti-factor Xa level may be helpful, particularly in patients >75 years of age or with CrCl ≤30 mL/minute	Remove catheter prior to the first postoperative dose Delay the first postoperative dose until ≥4 hours after catheter removal and ≥24 hours after needle or catheter placement, which ever is greater
Low dose (subcutaneous): Enoxaparin 30 mg every 12 hours Enoxaparin 40 mg daily Dalteparin 2500 to 5000 units daily	≥12 hours	First postoperative dose ≥12 hours after neuraxial procedure; subsequent dose ≥24 hours after the first dose For twice daily dosing: Remove catheter >4 hours prior to first postoperative dose For single daily dose during continuous epidural: Remove catheter 12 hours prior to next dose of LMWH, and subsequent dose should be >4 hours after removal	Epidural catheter may be maintained with once daily dosing, without administration of any other antihemostatic drugs.
Fondaparinux	High dose (5 to 10 mg once daily):	6 hours Remove catheter prior to first postoperative dose	It is acceptable to perform neuraxial block or remove a neuraxial catheter if a residual fondaparinux specific anti-factor Xa level is ≤0.1 IU/mL^*. Avoid neuraxial anesthesia in patients with CrCl <30 mL/minute.
	Patients with normal kidney function: Young patients – 70 hours Older patients – 105 hours Patients with CrCl 30 to 50 mL/minute – ASRA has not yet provided timing for needle placement for these patients, who would likely require intervals increased by 30% or more
	Low dose (2.5 mg once daily):
	Normal kidney function: Young patients – 36 hours Older patients – 42 hours CrCl 30 to 50 mL/minute – 58 hours
Direct thrombin inhibitors
Dabigatran	High dose (75 to 150 mg twice daily):		It is acceptable to perform neuraxial block or remove a neuraxial catheter if a residual dabigatran plasma level is <30 ng/mL^*. May be reversed with idarucizumab if necessary.
	CrCl >50 mL/minute – 72 hours CrCl 30 to 49 mL/minute – 120 hours, consider checking plasma dabigatran level	24 hours Remove catheter prior to first postoperative dose If unanticipated administration occurs with a catheter in place, withhold further doses for at least 72 hours for patients with CrCl ≥50 mL/minute, 120 hours for patients with CrCl 30 to 40 mL/minute, before removing the catheter, or measure dabigatran plasma level
	Low dose (110 to 220 mg once daily):
	48 hours	6 hours Remove catheter prior to first postoperative dose If unanticipated administration occurs with a catheter in place, withhold further doses for at least 48 hours before removing the catheter or measure dabigatran plasma level
Argatroban	Avoid neuraxial techniques
Hirudin derivative (bivalirudin)	Avoid neuraxial techniques
Antiplatelet medication
Platelet P2Y12 receptor blockers
Clopidogrel	5 to 7 days	Without loading dose: Immediate With loading dose: 6 hours	Neuraxial catheters can be maintained for 1 or 2 days if no loading dose will be administered.
Prasugrel	7 to 10 days	Without loading dose: Immediate With loading dose: 6 hours	Neuraxial catheters should not be maintained after administration of prasugrel.
Ticlopidine	10 days	Without loading dose: Immediate With loading dose: 6 hours	Neuraxial catheters can be maintained for 1 or 2 days if no loading dose will be administered.
Ticagrelor	5 days	Without loading dose: Immediate With loading dose: 6 hours	Neuraxial catheters should not be maintained after administration of ticagrelor.
Cangrelor	3 hours	8 hours Remove catheter prior to first postoperative dose
Platelet GP IIb/IIIa inhibitors			Contraindicated for 4 weeks after surgery; monitor neurologic status if given after neuraxial technique.
Tirofiban	4 to 8 hours
Eptifibatide	4 to 8 hours
Abciximab	24 to 48 hours
Cilostazol	2 days	6 hours Remove catheter ≥6 hours prior to first postoperative dose
Dipyridamole	24 hours	Remove catheter ≥6 hours prior to first postoperative dose
Aspirin	May continue dosage	May continue dosage	Affects platelet function for the life of the platelet (up to 7 days). Avoid neuraxial techniques on aspirin if early postoperative use of other anti-hemostatic drugs (including heparin) is anticipated.
NSAIDs (nonsteroidal antiinflammatory drugs)	May continue dosage	May continue dosage	Effect on platelet function normalizes within 3 days. Avoid neuraxial techniques on NSAIDs if early postoperative use of other anti-hemostatic drugs (including heparin) is anticipated. COX-2 inhibitors (celecoxib) have minimal effect on platelet function.
Warfarin	4 to 5 days and verify normal INR; no monitoring needed for single dose within 24 hours of placement		Some patients may require bridging anticoagulation. The decision to withhold warfarin for 5 versus 4 days should weigh the risk of surgical delay for an extra day versus the possibility that the INR may not have returned to normal at the time of surgery. Continue regular neurologic evaluation until 24 hours after removal. If dosed with catheter in place, check INR daily and remove when INR <1.5; if INR 1.5 to 3.0, remove catheter with caution, monitor neurologic status until INR stabilized; if INR >3, hold/reduce warfarin dose. Use of other antihemostatic medications that do not influence INR may increase risk of bleeding complications.
Herbal medications (garlic, ginkgo, ginseng)	May continue dosage	May continue dosage	Concurrent use with other anti-hemostatic drugs may increase bleeding risk.

Recommendations in this table reflect those that appear in the guidelines of the ASRA fifth edition^[1], unless otherwise specified. These recommendations were developed for clinicians performing neuraxial anesthesia but may also apply to those performing myelography or diagnostic or therapeutic lumbar puncture. Whereas these guidelines are applicable to parturients, they may be modified when urgent intervention is required for maternal or fetal indications if the risks of general anesthesia are thought to be greater than the risks of neuraxial anesthesia.

aPTT: activated partial thromboplastin time; ASRA: American Society of Regional Anesthesia and Pain Medicine; CrCl: creatine clearance; FDA: US Food and Drug Administration; HIT: heparin-induced thrombocytopenia; INR: international normalized ration; IV: intravenous; NA: neuraxial anesthesia; P2Y12: purinergic receptor P2Y; PT: prothrombin time.

* These values define an undetected anticoagulant effect, but do not guarantee safety of neuraxial anesthesia in patients taking these medications.

Reference:

Kopp SL, Vandermeulen E, McBane RD, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition). Reg Anesth Pain Med 2025.

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Timing of neuraxial anesthesia during antithrombotic therapy