Holding Anticoagulants for Interventional Pain Procedures

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Holding anticoagulants for interventional pain procedures

By Chris Faubel, M.D. —

The risk of performing interventional pain injections while a patient is taking anticoagulant blood thinners has been debated for years.  Previously, the most cautious guidelines called for holding anticoagulants not only all prescription anti-coagulants, but also over-the-counter NSAIDs, aspirin, and many herbs/vitamins (gingko, fish oil, vitamin E, etc) for varying numbers of days before the procedure.

Within the last few years, the risk of being taken off these blood thinners, even for a few days, has been shown to be more dangerous than keeping patients on them for certain procedures that are not near the spinal cord or nerves.

The below information regarding the cessation or holding of anticoagulants is for NEURAXIAL PROCEDURES.  With these procedures, there is a higher risk of epidural hematoma formation if a vein or artery is punctured near the spinal cord.

Neuraxial procedures (and other pain procedures with higher bleeding risk)
  • Epidural steroid injections (interlaminar and transforaminal)
  • Spinal cord stimulator trials and implants
  • Intrathecal pump placement
  • Kyphoplasty / vertebroplasty
  • Sympathetic ganglion blocks
  • Cervical and thoracic discograms

Note:  It is considered OKAY to continue anticoagulants for other spinal injections/procedures, such as facet (Z-joint) injections, medial branch blocks (MBBs), radiofrequency neurotomy (RFA) and lumbar discograms.

Important:  Keep in mind that every patient is different and multiple other variables may apply to the bleeding risk.  The below are just guidelines.  Also, always get permission from the prescribing physician prior to holding/stopping an anticoagulant.

Medication

Duration to Hold

Notes

aspirin / NSAIDs

May Continue

fish oil, vit. E, gingko, etc.

May Continue

warfarin (Coumadin)

5 days

INR < 1.3
clopidogrel (Plavix)

7 days

Do NOT stop if stent was placed in the past 12 months
aspirin/dipyridamole (Aggrenox)

3 days

Take a baby ASA those three days
dabigatran (Pradaxa)

2-4 days

Longer in renal impairment
enoxaparin (Lovenox)

12 hours (prophylaxis)

24 hours (therapeutic)

Longer in renal impairment
heparin

8 hours (prophylaxis)

when aPTT >40s (thera.)

dalteparin (Fragmin)

8 hours (prophylaxis)

24 hours (therapeutic)

Longer in renal impairment
fondaparinux (Arixtra)

48 hours (prophylaxis)

72 hours (therapeutic)

Longer in renal impairment
rivaroxaban (Xarelto)

18 hours (prophylaxis)

5 days (therapeutic)

Longer in renal impairment
drotrecogin (Xigris)

24 hours

Longer in renal impairment
ticagrelor (Brilinta)

5 days

abciximab (Reopro)

48 hours

ticlopidine (Ticlid)

10 days

apixaban (Eliquis)

2-3 days

Longer in renal impairment
prasugrel (Effient)

7 days

tirofiban (Aggrastat)

8 hours

Longer in renal impairment
alteplase (TPA) – full dose

10 days

Note:  Some of the above will not be encountered in an office-based practice because they are only given in a hospital setting.

** The above was collected from the American Society of Regional Anesthesia (ASRA) and the International Spine Intervention Society (ISIS)

Updated August 2013

 

4 COMMENTS

  1. I am getting a cortisone shot in lower back tomorrow 11-1. I stopped taking xarelto ssunday night. Last dose Saturday night. Cardiologist recommends staying off for three days after injection. What say you?

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