Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

Publication Date: April 1, 2018
Last Updated: March 14, 2022

Recommendations

Overview

The ASRA and European regional guidelines recommend that central neuraxial blocks may be performed in individuals utilizing ASA or NSAIDs. The Scandinavian guidelines for the performance of central neuraxial blocks in individuals utilizing ASA based their recommendations on the indication for ASA utilization and the daily dose. In individuals taking ASA for secondary prevention, a shorter discontinuation time of 12 hours was recommended. For individuals not using ASA for secondary prevention, the discontinuation time is 3 days unless the dose is greater than 1 g/d, for which the discontinuation time is extended to 1 week. For NSAIDs, the Scandinavian guidelines recommendations are guided by the specific half-life for each drug.
Data specifically defining the risk of bleeding with interventional pain medicine procedures with NSAID continuation remain limited since the first publication. Recently, small retrospective reviews evaluating bleeding complications in patients undergoing specific interventional pain procedures including joint injections, facet procedures, ESIs, percutaneous spinal cord stimulator trials and implantations, celiac plexus blocks, and intrathecal drug delivery systems have been published. Unfortunately, based on the inherent limitations of retrospective analyses and the small number of patients receiving NSAIDs, the ability to draw clinical conclusions and imply the safe performance of these interventional pain procedures while continuing NSAIDs and ASA is limited. Bleeding complications in individuals undergoing percutaneous spinal cord stimulator trial implantations were examined in 101 patients who had continued NSAIDs. In this retrospective review, only 48 patients were taking ASA, and 53 patients were taking NSAIDs. Patients were documented as taking ASA and NSAIDs if a dose was taken within 7 days of the procedure. A 7-day discontinuation time frame is an extended period for ASA and NSAIDs discontinuation based on the pharmacokinetics of the drugs. Many of these drugs can be stopped within 1 to 2 days, and the patient would not be expected to have any coagulation deficits or platelet deficiencies. Endres et al. examined bleeding complications in 4766 interventional pain procedures for which anticoagulants were continued. A majority of the procedures for which the anticoagulants were continued were for medial branch blocks (2074 patients), transforaminal ESIs (1633 patients), and trigger point injections (456 patients). In this analysis of 4766 interventional pain procedures for which anticoagulants were continued, only 60 patients continued ASA, for which more than 50% of the patients included those who underwent MBNBs. In addition, no interlaminar ESIs were performed with ASA. Therefore, significant limitations exist with the ability to declare safety when performing ESIs via the interlaminar approach while continuing ASA and NSAIDs. In this retrospective analysis, the sample sizes were small, and therefore, meaningful confidence intervals (CIs) around the observed prevalence for bleeding complications could not be provided. In addition because of the small sample size, procedures were not stratified according to cervical, thoracic, and lumbar segment levels. Therefore, it is unknown how many individuals had lumbar versus cervical procedures. For the MBNB patients, a large percentage of patients continued warfarin (1090/2074) and clopidogrel (890/2074). In order to fully determine the risk of continuing NSAIDs and ASA for specific pain procedures, larger numbers are required.
Aspirin has been identified as an important risk factor for postoperative bleeding and the development of hematomas including epidural hematomas in other surgical fields. Furthermore, the use of low-dose ASA before spine surgery, even when discontinued for at least 7 days, has been suggested to lead to further blood drainage after surgery. In an extensive review, low-dose ASA has also been shown to increase the rate of bleeding complications by a factor of 1.5 (median; interquartile range, 1.0–2.5). The baseline risk of bleeding varied based on surgical type (cataract surgery vs transurethral prostatectomy).
Bleeding complications also occur after the performance of interventional pain procedures. Spinal hematoma is a rare complication that has been associated with spinal cord stimulator trials, implants with percutaneously placed cylindrical leads and laminotomy-placed paddle leads, lead migration, revisions, and lead removal. Aspirin and NSAIDs have been suggested as a risk factor in some of the cases. Case reports of subdural hematomas following spinal anesthesia have also questioned ASA's continuation prior to a spinal anesthetic. In addition, spinal hematomas have occurred after cervical ESIs in individuals taking non-ASA NSAIDs. Other studies examining the performance of lumbar epidurals for pregnancy have not demonstrated an increased risk of bleeding complications with ASA. The CLASP (Collaborative Low-Dose Aspirin Study in Pregnancy) did not show an increase in bleeding complications when performing epidurals for pregnancy in individuals taking 60 mg of enteric-coated ASA daily.
Moreover, patients' comorbidities should be evaluated, as this may have a great impact on bleeding tendency. Specifically, renal dysfunction, including nephrotic syndrome, reduces NSAIDs' binding to plasma proteins, which can result in a larger volume of distribution and increased drug concentrations within tissues. Renal dysfunction can also prolong elimination half-life. Hepatic dysfunction may result in hypoalbuminemia and altered NSAID metabolism. Furthermore, alcohol and other pharmacological agents may potentiate the effects of both ASA and nonASA NSAIDs.
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ASA

  • A patient- and procedural-specific strategy is recommended when deciding whether to continue or discontinue ASA in the perioperative period for interventional pain procedures. Decision making should include an understanding of the reason for ASA utilization, the vascular anatomy surrounding the target area, the degree of invasiveness of the procedure, and the potential sequelae associated with perioperative bleeding.
  • In addition, a complete review of the patient's medical record should occur to identify additional medications that may heighten ASA's anticoagulant effect (eg, selective serotonin norepinephrine reuptake inhibitors [SNRIs] and dipyridamole).
  • If ASA is being taken for primary prophylaxis, ASA discontinuation is recommended for high-risk procedures in which there is a heightened risk of perioperative bleeding and sequelae. In addition, 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.
  • When ASA is being utilized for primary prophylaxis, ASA may be discontinued for a longer period, 6 days, to ensure complete platelet functional recovery.
  • In individuals utilizing ASA for secondary prophylaxis undergoing high-risk procedures, a shared assessment, risk stratification and management decision should involve the interventional pain physician, patient, and physician prescribing ASA. The risk of bleeding while continuing ASA needs to be weighed against the cardiovascular risks of stopping ASA. Documentation of decision making should occur. If a decision is made to discontinue chronic ASA therapy, the time of discontinuation should be determined individually.
  • When performing elective pain procedures where there is either a high risk of potential bleeding and/or the possibility of significant sequelae in an individual taking ASA for secondary prophylaxis, ASA should be discontinued for a minimum of 6 days. In individuals taking ASA for secondary prophylaxis who are undergoing low- or medium-risk procedures for which a decision has been made to discontinue, the length of discontinuation can be shortened to 4 days in an effort to balance the risks of procedural bleeding and cardiovascular events. Zisman et al. demonstrated that in most ASA-treated patients platelet function recovers 4 days after drug discontinuation.
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PDE Inhibitors

The decision to discontinue cilostazol or dipyridamole without ASA or combined with ASA should involve shared decision making between the interventional pain physician, patient, and prescribing physician.
  • For high-risk procedures, cilostazol and dipyridamole without ASA should be discontinued 48 hours prior to performing the intervention.
  • For intermediate- and low-risk procedures, cilostazol and dipyridamole without ASA do not need to be discontinued.
  • The discontinuation length for dipyridamole combined with ASA should follow the ASA recommendations described previously for high-, intermediate-, and low-risk procedures. It has been suggested when dipyridamole is combined with ASA the risk of bleeding is increased.
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Procedural Recommendations Regarding Duration of Spinal Cord Stimulator Trials

  • Currently, no consensus exists regarding the required duration for a spinal cord stimulator trial.
  • The length of the trial should be sufficient to demonstrate improvement in pain control and allow prospective patients the ability to determine if they desire to progress forward to the implantation stage. Chincholkar et al, in a prospective trial examining 40 patients who underwent a spinal cord stimulator trial, demonstrated that a majority of patients are able to make a decision at a mean duration of 5.27 days. Furthermore, most individuals who had a successful trial arrived at a decision earlier than did those with an unsuccessful trial. In addition, Weinand et al. did not demonstrate improvement in outcomes with a prolonged trial. In this study, individuals either had an acute (15 minute intraoperative) or prolonged (5-day) SCS screening trial. Both the acute and prolonged SCS screening had equivalent predictive values for successful long-term SCS pain control.
  • Because a platelet rebound phenomenon may occur with the discontinuation of ASA, and the time interval between ASA discontinuation and the occurrence of an acute cardiovascular event is in the range of 8 to 14 days, in individuals taking ASA for secondary prevention it is recommended that the length of the trial be minimized with a risk-benefit ratio considered for adequate trialing versus the possibility of cardiovascular sequelae.
  • The Neurostimulation Appropriateness Consensus Committee recommendations formed by the International Neuromodulation Society also published specific measures to reduce the risk of bleeding and neurological injury secondary to impairment of coagulation in the setting of implantable neurostimulation devices in the spine, brain, and periphery. These recommendations are aligned with the recommendations published here.
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Timing of Therapy Restoration

  • Because NSAIDs are not essential for cardiovascular protection, for high-risk procedures we recommend withholding these drugs for 24 hours after the procedure.
  • For elective pain procedures associated with a high risk of bleeding complications, ASA can be resumed 24 hours after the procedure if required for secondary prevention.
  • For primary prevention, ASA should not be restarted for at least 24 hours following high-risk procedures and specific intermediaterisk procedures, including interlaminar cervical ESIs and stellate ganglion blocks, where specific anatomical configurations may increase the risk and consequences of procedural bleeding. We recommend a delay because ASA rapidly and significantly affects platelet function after ingestion. Aspirin also influences thrombus stability and fibrinolysis. Clot stabilization probably typically occurs at 8 hours.
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P2Y12 Inhibitors: Ticlopidine, Clopidogrel, Prasugrel, Ticagrelor, Cangrelor

Procedural Recommendations

The ASRA and the European guidelines on regional anesthesia recommended a 7-day interval for clopidogrel, whereas the Scandinavian guidelines noted that 5 days is probably adequate. The Scandinavian guidelines are based on the 10% to 15% formation of new platelets every day, resulting in 50% to 75% of the circulating platelet pool being unaffected by platelets 5 days after stoppage of the antiplatelet drug. We recommend 7-day cessation of clopidogrel prior to spine or pain intervention. If 5 days is recommended by the managing cardiologist or vascular medicine physician, specifically prior to an extended SCS trial, then a test of platelet function should be performed to ensure adequate recovery of platelet function. For prasugrel, 7 to 10 days is advisable, whereas 5 days is adequate, for ticagrelor. A minimum of 3 hours should be observed in patients who had cangrelor infusion.
For resumption of the antiplatelet drug after a neuraxial procedure or catheter removal, the Scandinavian guidelines recommended that the drug be started after catheter removal, whereas the European guidelines recommended 6 hours after catheter removal before prasugrel and ticagrelor can be started. Baron et al. cautioned in restarting prasugrel and ticagrelor early because of their rapid effect and potent antiplatelet inhibition.
Clopidogrel can be restarted 12 to 24 hours after a spine procedure, in view of its slow onset. However, loading doses of clopidogrel, prasugrel, and ticagrelor take effect within 30 minutes to 6 hours. In these cases, a 24-hour interval is more appropriate. For prasugrel and ticagrelor, a 24-hour interval is recommended in view of their rapid antiplatelet effects.
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Summary Recommendations for P2Y12 Inhibitors

  • For low-risk procedures, the risks and benefits of stopping clopidogrel should be carefully assessed in conjunction with the treating physician(s). We believe that many, if not most, low-risk procedures can be safely done without discontinuing P2Y12 inhibitors.
  • We strongly recommend a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) for those patients with higher bleeding risk profiles, especially when
(1) taking concomitant antiplatelet medications,
(2) advanced patient age,
(3) advanced liver or renal disease, or
(4) a prior history of abnormal bleeding exists.
These factors should be assessed, against the risk of a thromboembolic event, should clopidogrel be stopped.
  • For medium- and high-risk procedures, clopidogrel should be routinely stopped for 7 days. In patients with high risk of thromboembolic events, we recommend a 5-day discontinuation interval, and if available, platelet function tests show adequate platelet function.
  • For trial of SCS, clopidogrel may be stopped for 5 days upon consultation with the prescribing physician to assess the risk-tobenefit ratio, but available tests of platelet function (such as the VerifyNow P2Y12 assay or the platelet mapping portion of the thromboelastograph) may be considered.
  • For medium- and high-risk procedures, prasugrel should be stopped for 7 to 10 days.
  • For medium- and high-risk procedures, ticagrelor should be stopped for 5 days.
  • For medium- and high-risk procedures, cangrelor should be stopped for a minimum of 3 hours.
  • When clopidogrel, prasugrel, or ticagrelor is stopped, a “bridge” therapy with a low-molecular-weight heparin (LMWH) may be instituted in patients with high risk of thromboembolic events (in consultation with the patient's managing physician). The LMWH will then be discontinued 24 hours before the interventional procedure.
  • After an intervention, the usual daily dose (75 mg) of clopidogrel can be started 12 hours later. If a loading dose of clopidogrel is used, there should be an interval of 24 hours.
  • Prasugrel and ticagrelor can be started 24 hours after a procedure, whether a usual clinical dose or a loading dose is given.
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Older Anticoagulants

Warfarin and Acenocoumarol

  • For low-risk procedures, the decision as to whether warfarin should be stopped should be considered in conjunction with the treating physician(s). We believe that many of these procedures may be safe in the presence of a therapeutic INR (INR <3.0).
  • We strongly recommend, however, a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) for those patients with higher bleeding risk, similar to the antiplatelet agents.
  • Warfarin should be stopped for 5 days and the INR normalized (≤1.2) before high- and intermediate-risk pain procedures.
  • Acenocoumarol should be stopped for 3 days and the INR normalized before high- and intermediate-risk pain procedures.
  • After the procedure, warfarin can be restarted the next day.
  • Alternatively, a bridge therapy with LMWH can be instituted in patients who are at high risk of thrombosis after consultation with the treating physicians.
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IV Heparin

  • Intravenous heparin should be stopped for at least 6 hours before a low-, medium-, or high-risk procedure is performed.
  • The IV heparin can be started a minimum of 2 hours after a pain procedure. If a moderate- or high-risk procedure was performed, especially if it was bloody, then a 24-hour interval should be observed.
  • Situations where pain procedures are performed in patients on IV heparin should rarely exist because alternative analgesics can help manage the pain until the intervention is performed when the patient is off the heparin.
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Subcutaneous Low-Dose Heparin

  • For patients on BID or TID dosing, intermediate-risk procedures (eg, ESIs) can be done 6 hours after the subcutaneous heparin.
  • For high-risk procedures (eg, SCS, intrathecal pump placements, vertebroplasty/kyphoplasty), we recommend an interval of 24 hours from the last dose of SC heparin and normalization of the aPTT/
  • The SC heparin can be restarted a minimum of 2 hours after the low-risk procedures but 6 to 8 hours after the intermediate- and high-risk procedures, when the clot has theoretically stabilized.
  • These scenarios should be avoided if possible. The patient's pain can be managed with alternative pharmacological therapies (opioids, anticonvulsants, antidepressants) until the procedure can be performed after the patient has discontinued SC heparin.
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LMWHs

  • We recommend a 12-hour interval between discontinuation of a prophylactic dose of enoxaparin (except when the dose is 1 mg/kg) and low-, medium-, and high-risk pain procedures.
  • When a therapeutic dose of enoxaparin (1 mg/kg) is used and likewise for dalteparin, we recommend a 24-hour interval between discontinuation of the drug and low-, medium-, and high-risk pain procedure.
  • The LMWH can be resumed 4 hours after low-risk pain procedures but at least 12 hours after intermediate- and high-risk pain procedures.
  • Concomitant drugs that affect hemostasis (antiplatelet, NSAIDs, SSRIs, other anticoagulants) should be used with extreme caution in patients on LMWH.
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Fibrinolytic Agents

Thrombolytic Agents

  • Interventional pain procedures should be avoided in patients who just had fibrinolytic agents. Other measures, including analgesic medications, should be attempted to manage the patient's pain. If an intervention has to be performed, a minimum of 48 hours between discontinuation of a thrombolytic agent and a neuraxial injection is probably safe. Longer intervals, ie, 72 hours, should be considered for high risk surgical pain procedures.
  • In emergency situations wherein a thrombolytic needs to be administered after a spine pain intervention, the pain service should preferably be informed. Shared assessment, risk stratification, and management decisions regarding the timing of administration of the fibrinolytic agent should be observed. If the patient has a neuraxial catheter or SCS lead, the device can be left in place. Fibrinogen levels can be determined and the device removed after 48 hours or after a minimum of 2 half-lives of the drug has elapsed.
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Fondaparinux

  • We recommend a 5-half-life, or 4-day, interval discontinuation of fondaparinux before medium- and high-risk pain procedures.
  • For low-risk procedures, a shared assessment, risk stratification, and management decision in conjunction with treating physician(s) should guide whether fondaparinux should be discontinued. If a more conservative approach is needed, then 2-half-life, or 2-day, interval is probably adequate.
  • For low-risk procedures, we recommend an interval of 6 hours before fondaparinux is resumed. For intermediate- and high-risk surgical pain procedures, then a 24-hour delay is suggested. This is in view of the short onset of the effect of fondaparinux.
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New Anticoagulants: Dabigatran, Rivaroxaban, Apixaban, Edoxaban

NOACs

  • We recommend a 5-half-life interval between discontinuation of any one of the new anticoagulants and medium- and high-risk pain procedures.
  • For low-risk procedures, a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) should guide whether these new anticoagulants should be stopped. A 2-half-life interval may be considered.
  • If the risk of VTE is high, then an LMWH bridge therapy can be instituted during stoppage of the anticoagulant, and the LMWH can be discontinued 24 hours before the pain procedure.
  • We recommend a 24-hour interval after interventional pain procedures before resumption of the new anticoagulants.
  • If the risk of VTE is very high, half the usual dose may be given 12 hours after the pain intervention. The decision regarding timing of drug resumption should be shared with the patient's other physician(s).
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Dabigatran
  • We recommend a 5-half-life interval, or 4 days, between discontinuation of dabigatran and medium- or high-risk pain procedure.
  • For low-risk procedures, a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) should guide whether dabigatran should be stopped. If a more conservative approach is desired, then 2 half-lives (2 days) may be considered.
  • For patients with end-stage renal disease, we recommend a 5- to 6-day interval because the half-life of dabigatran increases to 28 hours in this condition.
  • We recommend a 24-hour interval after interventional pain procedures before resumption of dabigatran. This recommendation is similar to recommendations after surgical procedures.
  • If the risk of VTE is very high, dabigatran may be given 12 hours after the pain intervention. The decision regarding timing of drug resumption should be shared with the patient's treating physician(s).
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Rivaroxaban
  • We recommend a 5-half-life interval, or 3 days, between discontinuation of rivaroxaban and medium- or high-risk pain procedures.
  • For low-risk procedures, a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) should guide whether rivaroxaban should be stopped. In these procedures with lower risk of bleeding, 2-half-life interval may be considered.
  • We recommend a 24-hour interval after interventional pain procedures before resumption of rivaroxaban.
  • If the risk of VTE is very high, half the usual dose may be given 12 hours after the pain intervention. The decision regarding timing of drug resumption should be shared with the patient's treating physician(s).
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Edoxaban

  • We recommend a 5-half-life interval, or 3 days, between discontinuation of edoxaban and medium- or high-risk pain procedures.
  • For low-risk procedures, a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) should guide whether edoxaban should be stopped. In these situations, 2-half-life interval may be considered.
  • We recommend a 24-hour interval after interventional pain procedures before resumption of edoxaban.
  • If the risk of VTE is very high, half the usual dose may be given 12 hours after the pain intervention. The decision regarding timing of drug resumption should be shared with the patient's other physician(s).
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Glycoprotein IIb/IIIa Inhibitors

Procedural Recommendations

All chronic interventional pain procedures are elective, and as such, extreme caution needs to be exercised in terms of timing of procedures in the patients receiving GP IIb/IIIa inhibitors. The actual risk of spinal hematoma or bleeding with GP IIb/IIIa antagonists is unknown. Management is based on labeling precautions and the known surgical and interventional cardiology experience. Caution needs to be observed if surgery is performed within 7 to 10 days of abciximab administration as this drug exerts a profound and irreversible effect on platelet aggregation. It is critical to determine the absolute platelet count before interventional pain procedures if patients have been on GP IIb/IIIa inhibitors to determine that there is no drug-induced thrombocytopenia. Although GP IIb/IIIa inhibitors are contraindicated immediately after surgery because of increased risk of bleeding, should one be administered in the postoperative period (after high- or intermediate-risk interventional pain procedure), we recommend that the patient have careful neurological monitoring for 24 hours.
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GP IIb/IIIa Inhibitors

  • Instances where an interventional pain procedure needs to be performed in a patient who is on or who just had GP IIb/IIa inhibitor are rare because these drugs are usually used in conjunction with percutaneous coronary procedures.
  • There are no studies on interventional procedures in patients on GP IIb/IIIa inhibitors. Shared decision making should therefore be observed in these instances.
  • For abciximab, recovery of platelet function occurs at 24 to 48 hours. However, platelet-bound abciximab is noted up to 10 days, and it causes irreversible binding, making recommendations on the interval between discontinuation of the drug and interventional procedure difficult to state. A minimum interval of 48 hours is recommended even for low-risk procedures. As there has been no study of platelet function after discontinuation of the drug, 5 days is probably adequate, based on daily formation of new platelets, for intermediateand high-risk procedures.
  • For eptifibatide and tirofiban, an 8-hour stoppage before a low-risk interventional procedure is probably adequate. For intermediate- and high-risk procedures, a 24-hour interval is ideal.
  • The GP IIb/IIa inhibitors have rapid onsets of actions, so an adequate time should be observed for the clot to stabilize. An 8- to 12-hour interval is probably adequate.
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Antidepressants and SRIs

Procedural Recommendations

The management plan should be individualized according to the type of pain procedure, type and dosage of antidepressants, severity of depression and suicide risk, other risk factors for bleeding, and concomitant use of antiplatelets and anticoagulants. Moreover, a shared assessment, risk stratification, and management approach should be coordinated with the treating psychiatrist/physician to assist with bridging to other nonserotonergic antidepressants, manage drug discontinuation syndromes, or treat worsening depression.
Because the absolute risk of abnormal bleeding with SSRIs is low, and uncontrolled depression is associated with poorer surgical outcome, routine discontinuation of SRIs before pain procedures is not recommended. Serotonin reuptake inhibitor discontinuation is probably necessary only in high-risk patients with stable depression. High-risk factors are elderly patients; those patients concomitantly using ASA, NSAIDs, other antiplatelets, or anticoagulants; and in those with liver cirrhosis or failure.
However, in high-risk patients with severe depression, suicidal risk, or history of uncontrolled discontinuation syndrome, switching from SRIs to nonserotonergic antidepressants (bupropion, mirtazapine, some TCAs) should be considered. This should involve shared decision making with other treating physicians.
Few TCAs and most SSRIs and SNRIs, such as fluoxetine, sertraline, paroxetine, escitalopram, duloxetine, and venlafaxine, have intermediate to high degrees of serotonin reuptake inhibition.In contrast, nonserotonergic antidepressants such as bupropion, mirtazapine, and some TCAs do not inhibit serotonin reuptake. In fact, intraoperative bleeding risk was not higher in the nonserotonergic antidepressant users than in nonusers. It has previously been shown that GI tract bleeding induced by high-dose fluoxetine resolved after switching to mirtazapine.
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Antidepressants

  • Routine discontinuation of SRIs before pain procedures is not recommended.
  • Patients with stable depression who are at a high risk of bleeding associated with SRI use (old age, advanced liver disease, and concomitant ASA, NSAID, antiplatelet, or anticoagulant use) should undergo gradual tapering of the SRI dose and discontinue usage 1 to 2 weeks before the procedure.
  • Gradual tapering of the dose is especially important in SRIs with known serious discontinuation symptoms (paroxetine or venlafaxine).
  • Fluoxetine is an exception because it has an active metabolite with a long half-life. The dose should be gradually tapered off and discontinued 5 weeks before planned procedure.
  • Patients with unstable depression or with suicidal risk, who are at a high risk of bleeding associated with SRI use, should be switched to nonserotonergic antidepressants that do not or less potently inhibit serotonin reuptake (eg, bupropion, mirtazapine, TCAs).
  • Serotonin reuptake inhibitors should be restarted as soon as possible after the disappearance of the bleeding risk from the procedure, usually the next day.
  • Perioperative management of SRIs should be coordinated with the treating psychiatrist.
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Herbal/Alternative and Dietary Supplements

Herbal Medications and Dietary Supplements

  • Physicians should inquire about the use of herbal/alternative therapies and make this part of the reconciled medication list, with actual dosages of the agent, if possible. Practitioners should be aware that these agents are not regulated like FDA-approved drugs are, thus the potential for widely disparate amounts.
  • High-risk procedures are most likely to have a significant bleeding risk. Although there are no published cases, these completely elective procedures requiring extensive forethought and screening should be performed in idealized settings, that is, with discontinuation of several known herbal agents and dietary supplements with known coagulation risks.
  • Lower- and medium-risk procedures are probably safe as long as other anticoagulants have been stopped according to the guidelines for those particular agents. However, patients who have other risk factors, such as advanced age, renal and/or hepatic disease, history of major bleeding episodes from procedures, and so on, should likewise have these preparations stopped, even if the procedures are low to medium risk.
  • Timing of cessation is likely variable, but a 1-week period seems appropriate, given that many of the involved agents pose risks due to effects on platelet aggregation and/or potentiation of warfarin effect.
  • As the antiplatelet effect of garlic is dose dependent, we recommend inquiry as to the daily dose of garlic intake. Test of platelet function should be ordered when patients with several comorbidities take doses greater than 1000 mg/d or when there is concomitant intake with ASA, NSAIDs, or SSRIs.
  • In patients taking warfarin and also dong quai, the INR should be checked before medium- and high-risk procedures. The herb should be discontinued when the INR is markedly elevated. Refer to the section on warfarin regarding recommendations for interventional procedures.
  • In patients taking warfarin and also danshen, the INR should be checked before medium- and high-risk procedures. The herb should be stopped when the INR is markedly elevated. Refer to the section on warfarin regarding recommendations for interventional procedures. As there can be inhibition of platelet aggregation, interaction between danshen and other antiplatelet drugs (ASA, NSAIDs, SSRIs) should be kept in mind, especially in patients with several comorbidities.
  • In patients taking G. biloba and other antiplatelets (ASA, NSAIDs, SSRIs), a test of platelet function should probably be ordered before high-risk procedures. Refer to the section on antiplatelets regarding guidelines on their discontinued or continued use.
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Dietary Supplements

  • Vitamin E at doses greater than 400 IU daily may require caution when performing high-risk procedures. Cessation timing should be similar to other drugs whose effects on platelet activity, such as ASA, are considered.
  • Although fish oil effects remain unlikely to be major sources of bleeding, caution also suggests they be treated similar to other antiplatelet agents with 6-day stoppage prior to high-risk procedures, such as spinal cord or dorsal root ganglion stimulation.
  • Unless history suggests other sources of bleeding, low- and intermediate-risk procedures likely require no change in fish oil consumption at normal daily doses (~1000 mg/d).
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Pentosan Polysulfate Sodium

  • We recommended 5-day discontinuation of pentosan polysulfate sodium prior to intermediate- and high-risk procedures.
  • Pentosan polysulfate sodium can be resumed 24 hours after the conclusion of the procedure.
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Recommendation Grading

Overview

Title

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

Authoring Organization

American Society of Regional Anesthesia and Pain Medicine

Publication Month/Year

April 1, 2018

Last Updated Month/Year

June 7, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To determine the safe practice patterns of pain physicians regarding continuance of concurrently administered anticoagulants, timing schedules for cessation and resumption of use, and any use of “bridging” therapies when planning for various interventional pain procedures.

Target Patient Population

Patients on Antiplatelet and Anticoagulant Medications who undergo Interventional Spine and Pain Procedures

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D000925 - Anticoagulants, D059408 - Pain Management, D013131 - Spine

Keywords

anticoagulation, antiplatelet agents, Pain Management, Anticoagulation

Source Citation

Reg Anesth Pain Med 2018;43: 225–262