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American Society of Interventional Pain PhysiciansInterventional Pain Management2019advanced

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques

Published by American Society of Interventional Pain Physicians · Modified approach to grading of evidence based on Cochrane Review and USPSTF criteria (Levels I-V)

13Recommendations
320References
18Tables
7Figures
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Summary

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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.

interventional painantithromboticsanticoagulantsaspirinASIPPpain medicineguidelinesrecommendations

Key Takeaways

  • 1
    Interventional techniques are classified into low, intermediate, and high bleeding risk categories.
  • 2
    Thromboembolic risks from stopping antithrombotic therapy are generally higher than bleeding risks from continuing it.
  • 3
    Low-dose aspirin should be discontinued 3 days before moderate and high-risk procedures but can be continued for low-risk procedures.
  • 4
    Epidural hematoma requires immediate recognition (severe pain, motor dysfunction) and prompt MRI and surgical evaluation within 12 hours.

What's New in This Version

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.

Key Recommendations

5.0 Recommendations

  • 1

    Risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk, with upgrades based on other risk factors.

    Evidence: GoodRisk Assessment
  • 2

    Recognition of the risk of thromboembolic events in patients who interrupt antithrombotic therapy.

    Evidence: GoodClinical Management
  • 3

    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.

    Evidence: Good/ModerateMedication Management
  • 4

    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.

    Evidence: GoodMedication Management
  • 5

    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.

    Evidence: GoodDiagnosis/Treatment
  • 6

    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.

    Evidence: GoodPerioperative Management
  • 7

    The risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques.

    Evidence: FairRisk Assessment
  • 8

    Multiple variables including anatomic pathology (spinal stenosis, ankylosing spondylitis), procedural risk levels, observed bleeding, and multiple attempts increase the risk for bleeding complications.

    Evidence: FairRisk Assessment
  • 9

    Discontinuation of phosphodiesterase inhibitors (dipyridamole, cilostazol) is optional, but Aggrenox should be discontinued 3 days prior to moderate and high risk techniques.

    Evidence: FairMedication Management
  • 10

    Make shared decision making between the patient and the treating physician to consider all appropriate risks associated with continuation or discontinuation of therapy.

    Evidence: FairClinical Management
  • 11

    If thromboembolic risk is high, antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed.

    Evidence: FairMedication Management
  • 12

    Discontinuation of antiplatelet therapy (clopidogrel, ticlopidine, ticagrelor, prasugrel) avoids complications of significant bleeding and epidural hematomas.

    Evidence: LimitedMedication Management
  • 13

    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.

    Evidence: Very LimitedMedication Management

Scope & Objectives

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

Interventional pain physiciansAnesthesiologistsPain medicine specialists

Patient Criteria & Setting

Therapeutic Area

Pain Medicine

Guideline Scope

Risk AssessmentPerioperative ManagementBest Evidence Synthesis

Inclusion Criteria

  • Systematic reviews
  • Non-systematic reviews
  • Observational studies
  • Randomized controlled trials
  • Case reports

Care Settings

Outpatient clinicsAmbulatory surgical centersHospitals

Special Populations

Elderly patientsPatients with spinal stenosisPatients with ankylosing spondylitisPatients with renal insufficiencyPatients with liver disease

Evidence Grading

System: Modified approach to grading of evidence based on Cochrane Review and USPSTF criteria (Levels I-V)

Evidence Levels

Level IStrong: Evidence obtained from multiple relevant high quality randomized controlled trials for effectiveness
Level VConsensus based: Opinion or consensus of large group of clinicians and/or scientists
Level IIModerate: Evidence obtained from at least one relevant high quality randomized controlled trial or multiple relevant moderate or low quality randomized controlled trials
Level IVLimited: Evidence obtained from multiple moderate or low quality relevant observational studies
Level IIIFair: Evidence obtained from at least one relevant high quality nonrandomized trial or observational study with multiple moderate or low quality observational studies

Recommendation Strength

WeakSome confidence that the recommendation offers the best current guidance based on limited evidence.
StrongHigh confidence that the recommendation reflects best practice based on strong evidence for a true net effect.
ModerateModerate confidence that the recommendation reflects best practice based on good evidence.

Safety & Contraindications

Contraindications

  • Cilostazol in patients with severe renal insufficiency

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.

Authors & Contributors

Alan D. KayeLaxmaiah ManchikantiMatthew B. NovitchImran N. MungrueMuhammad AnwarMark R. JonesErik M. HelanderElyse M. CornettMatthew R. EngJay S. GriderMichael E. HarnedRamsin M. BenyaminJohn R. SwicegoodThomas T. SimopoulosSalahadin AbdiRichard D. UrmanTimothy R. DeerCyrus BakhitMahendra SanapatiSairam AtluriRamarao PasupuletiAmol SoinSudhir DiwanRicardo VallejoKenneth D. CandidoNebojsa Nick KnezevicDouglas BeallSheri L. AlbersRichard LatchawHari PrabhakarJoshua A. Hirsch

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryDrug interactions discussed

Learning Context

Difficulty

advanced

Exam Relevance

Pain Medicine Board ExamAnesthesiology Board Exam

Learning Paths

Interventional Pain ManagementAnticoagulationPerioperative MedicineEpidural HematomaRisk Stratification