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Published by American Society of Interventional Pain Physicians · Modified approach to grading of evidence based on Cochrane Review and USPSTF criteria (Levels I-V)
These guidelines provide evidence-based recommendations on the perioperative management of antithrombotic and anticoagulant therapy for patients undergoing interventional pain procedures, stratifying interventions into low, intermediate, and high bleeding risks to minimize adverse events like epidural hematomas and thromboembolisms.
Key Takeaways
These guidelines update the 2013 ASIPP guidelines. They differ significantly from ASRA guidelines by stratifying procedures differently (e.g., classifying cervical/thoracic epidurals as high-risk) and re-evaluating the balance of thromboembolic risk versus bleeding risk.
Risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk, with upgrades based on other risk factors.
Recognition of the risk of thromboembolic events in patients who interrupt antithrombotic therapy.
Discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and continuation for low risk or some intermediate risk procedures.
Discontinuation of anticoagulant therapy (warfarin, heparin, dabigatran, rivaroxaban, apixaban, etc.) prior to interventional techniques with individual consideration of pharmacokinetics and individual risk factors increases safety.
Diagnosis of epidural hematoma is based on severe pain at the site of injection, rapid neurological deterioration, and MRI, with surgical decompression to avoid neurological sequelae.
If thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and discontinued 24 hours before the pain procedure.
The risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques.
Multiple variables including anatomic pathology (spinal stenosis, ankylosing spondylitis), procedural risk levels, observed bleeding, and multiple attempts increase the risk for bleeding complications.
Discontinuation of phosphodiesterase inhibitors (dipyridamole, cilostazol) is optional, but Aggrenox should be discontinued 3 days prior to moderate and high risk techniques.
Make shared decision making between the patient and the treating physician to consider all appropriate risks associated with continuation or discontinuation of therapy.
If thromboembolic risk is high, antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed.
Discontinuation of antiplatelet therapy (clopidogrel, ticlopidine, ticagrelor, prasugrel) avoids complications of significant bleeding and epidural hematomas.
Discontinue most NSAIDs (excluding aspirin) for 1 to 2 days and some 4 to 10 days, as these are utilized for pain management without cardiac or cerebral protective effect.
Clinical Topic
Interventional Pain Management
Objectives
To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications.
Target Patient Population
Patients undergoing interventional pain management techniques while taking anticoagulant or antithrombotic therapy.
Diagnostic Criteria
Diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI.
Target Providers
Therapeutic Area
Pain MedicineGuideline Scope
Inclusion Criteria
Care Settings
Special Populations
System: Modified approach to grading of evidence based on Cochrane Review and USPSTF criteria (Levels I-V)
Evidence Levels
Recommendation Strength
Contraindications
Monitoring Guidance
Hemostasis is monitored using standard tests including platelet count, APTT, and INR. An INR of less than 1.5 is ideal for high and moderate risk procedures.
Difficulty
advanced
Exam Relevance
Learning Paths