Anticoagulants and antiplatelets for interventional pain procedures

Classify the procedure's bleeding risk first: neuromodulation implants, intrathecal pumps, deep sympathetic blocks and vertebral augmentation are high risk and need antithrombotic interruption, while low-risk procedures often proceed without stopping therapy.

1. High-risk procedures can paralyze. ASRA-led and ASIPP guidelines class spinal cord stimulator trials and implants as high bleeding risk because epidural hematoma can cause permanent paralysis ¹².
2. ASIPP's high-risk list is broad. It includes deep sympathetic blocks and neurolysis (stellate, splanchnic, celiac, lumbar sympathetic, hypogastric), intrathecal implants, vertebral augmentation and percutaneous decompression ².
3. DOAC holds differ by society. For high-risk procedures ASIPP stops DOACs for 2 days (1 day for intermediate risk), longer for dabigatran with CrCl below 50; ASRA advises a 3-day apixaban hold, restarting about 24 hours later ²³.
4. Warfarin is managed by INR. ASIPP accepts INR ≤3.0 for low-risk, ≤2.0 for intermediate-risk and <1.5 for high-risk procedures, stopping warfarin 3–5 days for the last ².
5. Antiplatelets have fixed intervals. ASIPP stops clopidogrel and prasugrel 6 days and ticagrelor 5 days for high-risk procedures; aspirin is stopped 6 days for high risk but may continue for lower tiers ².
6. Bridge only when thrombotic risk is high. ASIPP allows LMWH bridging for high thromboembolic risk, stopped 24 hours before the procedure; PAUSE showed DOAC interruption without bridging had low bleeding and stroke rates ²⁴.

Unexpected pain at the injection site with rapid neurologic deterioration suggests epidural hematoma: confirm with MRI and obtain urgent neurosurgical consultation to avoid permanent neurologic sequelae ².

• ASIPP restarts antithrombotics 12–24 hours after intermediate-risk and 24–48 hours after high-risk procedures, depending on bleeding ².
• With high thromboembolic risk, ASIPP allows resuming therapy 12 hours after the intervention ².
• For low-risk procedures, ASIPP allows DOACs to continue ².
• PAUSE omitted DOACs 1 day before low-risk and 2 days before high-risk procedures, without heparin bridging or coagulation testing ⁴.
• In PAUSE, 30-day major bleeding was 1.35% with apixaban and 1.85% with rivaroxaban ⁴.
• CHEST's 2022 guideline issued 44 recommendations, only two strong, including against bridging in atrial fibrillation ⁵.
• SSRIs raise bleeding risk, but ASIPP notes stopping them can trigger depressive relapse, so guidance is controversial ².
• Most NSAIDs other than aspirin may be held 1–2 days, some 4–10 days, for moderate and high-risk procedures ².

• Continuing clopidogrel through a high-risk neuraxial implant ².
• Reflexively bridging atrial fibrillation patients; CHEST strongly recommends against heparin bridging in atrial fibrillation ⁵.
• Mixing society intervals: ASIPP and ASRA give different DOAC hold times for the same high-risk procedure ²³.
• Using pain-procedure intervals for epidural or peripheral catheters; the separate ASRA regional anesthesia guideline (fifth edition, 2025) covers those ⁶.