Updates to the ASRA Guidelines for Interventional Pain Procedures
Specialty-specific guidelines on the management of anticoagulation in patients undergoing peripheral and neuraxial pain procedures are needed, according to attendees of ASRA’s 11th Annual Chronic Pain Meeting. In 2015, that issue came to fruition with the publication of consensus guidelines clarifying preprocedural and postprocedural management of nine classes of medications. Those guidelines also codified the practices of most interventionalists regarding evaluation and assessment of periprocedural bleeding risk via the Procedural Anticoagulation Management Checklist. A framework for risk assessment and stratification was also created on the basis of procedural risks, relevant anatomy, and potential for severe neurological injury.
Although the framework for evaluating periprocedural risk remained essentially unchanged, in April 2018 notable updates were released in several areas, including risk reclassification of some pain procedures, new recommendations for newer medications, recommendations for dietary supplements, and adjusted recommendations for heparin and fondaparinux. The update includes additional evidence supporting diligence in the management of novel oral anticoagulants (NOACs) before and after neuraxial interventions, recommendations for considering coagulation studies in patients with renal or hepatic disease, and recommendations for routine use of physical examination findings for signs or symptoms of coagulopathy.
As expected, the committee included dorsal root ganglion stimulation and percutaneous decompression laminectomy as new entrants to the high-risk procedure category. The categorization aligns ASRA guidelines with those published by the International Neuromodulation Society. Thoracolumbar facet procedures were transitioned to the low-risk category reflective of data released in 2017. Other changes include reducing peripheral nerve stimulation (PNS), PNS implantation, and device pocket revision to the low-risk category as well. The changes are worth noting because nearly all summary recommendations in the publication require assessing procedural risk to establish appropriate medication management.
As expected, the committee included dorsal root ganglion stimulation and percutaneous decompression laminectomy as new entrants to the high-risk procedure category. The categorization aligns ASRA guidelines with those published by the International Neuromodulation Society.
Authors included new recommendations and considerations for spinal cord stimulation (SCS) therapy, which are aligned with those from the International Neuromodulation Society. Adverse platelet physiology following discontinuation of aspirin (ASA) coupled with the rare need for extended SCS trials led authors to advocate for shorter SCS trials in patients using ASA for secondary prevention. Similar to recommendations for other intermediate and high-risk procedures, the committee recommends stopping clopidogrel seven days prior to SCS procedures with rare consideration of a five-day window coupled with platelet function testing to confirm recovery of function.
Noteworthy changes were made to recommendations surrounding intravenous (IV) heparin, subcutaneous heparin, and fondaparinux. The previous recommendation for a minimum window of 4 hours between cessation of IV heparin and performance of any interventional procedure was increased to 6 hours. Conversely, the waiting period following subcutaneous heparin was decreased from 8–10 hours to a current recommendation of 6 hours. Authors noted that performance of elective, interventional procedures in patients receiving the aforementioned medications should be rare.
Although the recommendations for holding and restarting NOACs remain unchanged, a new entrant into the category, edoxaban, was included. In general, recommendations for that class of medication include stopping it 3 days prior to a procedure, which represents a five half-life interval (a recurring theme across several drug classes). Three cases of serious, adverse bleeding in patients taking NOACs were reported, one of which was associated with removal of an epidural catheter.
As a compliment to the previous recommendations on supplements, new recommendations discussed vitamin E, fish oil, and pentosan polysulfate (a medication used in the treatment of interstitial cystitis). Interventionalists must remain aware of potentiating antiplatelet effects in patients taking supplements and direct antiplatelet agents simultaneously.
Table 1: Recommended Timeframes for Stopping Medications Before Surgery
|Drug||When to Stop||When to Restart|
|High-Risk Procedures||Intermediate-Risk Procedures||Low-risk Procedures|
|ASA and ASA Combinations||Primary prophylaxis: 6 days |
Secondary prophylaxis: shared assessment and risk stratification
|Shared assessment and risk |
|NSAIDs||5 half-lives||Noc||No||24 hr|
|Cilostazol||2 days||No||No||24 hr|
|ASA combination||Follow ASA reccomenations||Shared assessment and risk stratificationa|
|Coumadin||5 days, normal INR||5 days, normal INR||No, shared assessment and risk stratificationa||6 hr|
|Acenocoumarol||3 days, normal INR||3 days, normal INR||No, shared assessment and risk stratificationa||24 hr|
|IV heparin||6 hr||6 hr||6 hr||2 hrd|
|Subcutaneous heparin, BID and TID||24 hr||6 hr||6 hr||2 hr (low-risk procedures) 6–8 hr (intermediate-/high-risk procedures)|
|Enoxaprin (prophylactic)||12 hr||12 hr||12 hr||4 hr (low-risk) 12–24 hr (intermediate-/high-risk procedures)|
|Enoxaprin (therapeutic)||24 hr||24 hr||24 hr||4 hr (low-risk) 12–24 hr (intermediate-/high-risk procedures)|
|Dalteparin||24 hr||24 hr||24 hr||4 hr (low-risk) 12–24 hr (intermediate-/high-risk procedures)|
|Fibrinolytic agents||48 hr||48 hr||48 hr||NAe|
|Fondaparinux||4 days||4 days||Shared assessment stratification||6 hr (low-risk procedures) 24 hr (intermediate-/high-risk procedures)|
|Clopidogrel||7 days||7 days||No, shared assessment and risk stratification||12-24 hra|
|Prasugrel||7-10 days||7-10 days||No, shared assessment and risk stratification||24 hr|
|Ticagrelor||5 days||5 days||No, shared assessment and risk stratification||24 hr|
|Cangrelor||3 hr||3 hr||Shared assessment and risk stratification||24 hr|
|Dabigatran||4 days 5-6 days (impaired renal function)||4 days 5-6 days (impared renal function)||Shared assessment and risk stratificationa||24 hr|
|Rivaroxaban||3 days||3 days||Shared assessment and risk stratificationa||24 hr|
|Apixaban||3 days||3 days||Shared assessment and risk stratificationa||24 hr|
|Edoxaban||3 days||3 days||Shared assessment and risk stratificationa||24 hr|
|GP IIb/IIIa inhibitors|
|Abciximab||2-5 days||2-5 days||2-5 days||8-12 hr|
|Eptifibatide||8-24 hr||8-24 hr||8-24 hr||8-12 hr|
|Tirofiban||8-24 hr||8-24 hr||8-24 hr||8-12 hr|
|Antidepressants and SRIs||See text and Table 7||No||No||See text and Table 7|
ASA, aspirin; BID, twice daily; ESIs, XXX; GP, XXX; INR, XXX; IV, intravenous; LMWH, low-molecular-weigh heparin; NA, XXX; NOACs, novel oral anticoagulants; NSAIDs, nonsteroidal anti-inflammatory drugs; SRIs, XXX; TID, three times daily.
From Narouze S, Benzon HT, Provenzano D, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (second edition). Reg Anesth Pain Med. 2018;43:225–262. Used with permission.
a See detailed text in corresponding section.
b Consideration should be given to the discontinuation of ASA for certain intermediate-risk procedures including interlaminar cervical ESIs and stellate ganglion where specific anatomical configuration may increase the risk of consequences of procedural bleeding.
c Consideration should be given to the discontinuation of NSAIDs for certain intermediate-risk procedures including interlaminar cervical ESIs and stellate
ganglion blocks where specific anatomical configurations may increase the risk and consequences of procedural bleeding (refer to the section entitled Anatomical Considerations for Hematoma Development in Spinal and Nonspinal Areas).
d If a moderate- or high-risk procedure was bloody, then a 24-hour interval should be observed.
e After an intervention, the usual daily dose (75 mg) of clopidogrel can be started 12 hours later. If a loading dose of clopidogrel is given, then the interval should be 24 hours.
As previously noted, considerable changes have been made to recommendations surrounding the management of antiplatelet and anticoagulant medications in patients receiving interventional spine and pain procedures. Regardless, the document’s general themes remain unchanged: identify procedural risk, maintain an accurate list of all medications with direct or indirect anticoagulating effects for each patient, and stratify risk in consultation with other treating physicians to produce reliably safe outcomes for our patients. See Table 1 for a summary from the publication.
- Narouze S, Benzon HT, Provenzano D, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of pain Medicine, the international Neuromodulation Society, the North American Neuromodulation Society, and the world Institute of Pain. Reg Anesthes Pain Med. 2015;40:182–212. https://doi.org/10.1097/AAP.0000000000000223
- Narouze S, Benzon HT, Provenzano D, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesthes Pain Med. 2018;43:225–262. https://doi.org/10.1097/AAP.0000000000000700
- Deer TR, Narouze S, Provenzano DA, et al. The Neurostimulation Appropriateness Consensus Committee (NACC): recommendations on bleeding and coagulation management in neurostimulation devices. Neuromodulation. 2017;20(1):51–62. https://doi.org/10.1111/ner.12542