I. Antiplatelet medications |
1. Aspirin, NSAIDs, COX-2 inhibitors |
May continue |
Pain clinic patients: Aspirin preferably stopped 2–3 days in thoracic and cervical epidurals (author's preference—see text) |
2. Thienopyridine derivatives |
a. Clopidogrel (Plavix)—discontinue for 7 days |
b. Ticlopidine (Ticlid)—discontinue for 14 days |
Do not perform a neuraxial block in patients on more than one antiplatelet drug |
3. GPIIB/IIIA inhibitors: Time to normal platelet aggregation |
a. Abciximab (Reopro) = 24–48 h |
b. Eptifibatide (Integrilin) = 4–8 h |
c. Tirofiban (Aggrastat) = 4–8 h |
Antiplatelet medications (ASA, Plavix) are usually given after GPIIb/IIIa inhibitors. The above
guidelines on aspirin and Plavix should be adhered to |
II. Warfarin |
Check INR |
INR ≤ 1.5 before neuraxial block or epidural catheter removal |
III. Heparin |
1. Subcutaneous heparin (5000 units SQ q 12 h) |
Subcutaneous heparin is not a contraindication against a neuraxial block |
Neuraxial block should preferably be performed before SQ heparin is given |
Risk of decreased platelet count with SQ heparin therapy > 5 days |
2. Intravenous heparin |
Neuraxial block: 2–4 h after the last intravenous heparin dose |
Wait ≥ 1 h after neuraxial block before giving intravenous heparin |
IV. Low-molecular-weight heparin (LMWH) |
No concomitant antiplatelet medication, heparin, or dextran |
1. LMWH Preop |
a. Wait 12 h before a neuraxial block: |
b. Enoxaparin (Lovenox) 0.5 mg/kg bid (prophylactic dose) |
c. Wait 24 h before a neuraxial block: |
d. Enoxaparin (Lovenox), 1 mg/kg bid (therapeutic dose) |
e. Enoxaparin (Lovenox), 1.5 mg/kg qd |
f. Dalteparin (Fragmin), 120 units/kg bid |
g. Dalteparin (Fragmin), 200 units/kg qd |
h. Tinzaparin (Innohep), 175 units/kg qd |
2. LMWH Postop: |
a. LMWH should not be started until after 24 h after surgery |
b. LMWH should not be given until ≥ 2 h after epidural catheter removal |
3. Patients with epidural catheter who are given LMWH |
The catheter should be removed at the earliest opportunity. |
Enoxaparin (0.5 mg/kg): Remove the epidural catheter ≥ 12 h after last dose. |
Enoxaparin (1-1.5 mg/kg), dalteparin, tinzaparin: Remove the epidural catheter ≥ 24 h after last dose |
Restart the LMWH ≥ 2 h after the catheter removal |
Summary recommendations for LMWH (preop & postop): |
Wait 24 h except for patients on low-dose enoxaparin (0.5 mg/kg) in which case a 12 h interval is adequate |
Wait 2 h after the catheter is removed before starting LMWH |
V. Specific Xa inhibitor: Fondaparinux (Arixtra) |
Short onset, long duration (plasma half-life: 21 h) |
ASRA: No definite recommendation |
If neuraxial procedure must be performed, recommend single-needle atraumatic placement, avoid indwelling catheter |
VI. Fibrinolytic/Thrombolytic drugs |
No data on safety interval for performance of neuraxial procedure |
Follow fibrinogen levels |
ASRA: No definite recommendation |
VII. Thrombin Inhibitors |
Desirudin (Revasc) |
Lepirudin (Refludan) |
Bivalirudin (Angiomax) |
Argatroban (Acova) |
Anticoagulant effect lasts 3 h |
Monitored by aPTT |
ASRA: No recommendation at this time because of paucity of data |
VIII. Herbal therapy |
Mechanism of anticoagulant effect and time to normal hemostasis: |
Garlic: Inhibits platelet aggregation, increased fibrinolysis; 7 days |
Ginko: Inhibits platelet-activating factor; 36 h |
Ginseng: Increased PT and PTT; 24 h |
ASRA: Neuraxial block not contraindicated for single herbal medication use |
No data on combined herbal therapy |