Table 3.1-6. Timing of procedures in patients treated with antithrombotic drugsa

Agent

Lumbar puncture (with or without catheter introduction)

Removal of epidural or spinal catheter in patients treated with anticoagulantsb

Starting antithrombotic prophylaxis after spinal or epidural anesthesia

ASA

No restrictions

No restrictions

No restrictions

Clopidogrel

≥7 days from drug discontinuation (min 5)

After catheter removal

Prasugrel

≥10 days from drug discontinuation (min 7)

≥10 days from drug discontinuation

After catheter removal

Ticagrelor

≥5 days from drug discontinuation (min 3)

After catheter removal

Vitamin K antagonistc

4 days from drug discontinuation + normal INR

When INR <1.5

After catheter removal

IV UFH

4 h after discontinuation of IV infusion and normalization of aPTT

4 h after discontinuation of infusion and normalization of aPTT

– >2 h after removal of catheter

– Defer by 12 h in case of bloody puncture (applies to intraoperative use of IV UFH)

SC UFH

4 h after SC injection of prophylactic dose

4 h after SC injection of prophylactic dose

1 h after removal of catheter

SC LMWH

– 10-12 h after standard prophylactic dose

– 24 h after last therapeutic dose and after normalization of anti-Xa activity

– 10-12 h after last dose and 4 h before next dose

– 24 h after last dose (with doses administered every 24 h)

– 2-4 h after removal of catheter

– Defer by 24 h in case of bloody puncture (applies to therapeutic dose)

Fondaparinux

– 24-36 h after standard prophylactic dose (2.5 mg SC every 24 h)

– 48-72 h after standard therapeutic dose (7.5 mg SC every 24 h)

36-42 h after last dose (no data available on safety of fondaparinux in patients with indwelling spinal or epidural catheters; other anticoagulants should be used)

– 6-12 h after removal of catheter in patients receiving prophylactic doses (2.5 mg SC every 24 h)

– 12-24 h after removal of catheter in patients receiving therapeutic doses (7.5 mg SC every 24 h) or in patients at high bleeding risk

Oral factor Xa inhibitord

Hold day of procedure and 2 days prior (>48 h after last dose)

Hold day of procedure and 2 days prior (>48 h after last dose)

6-12 h after removal of catheter in patients starting prophylactic dosesf

≥24 h after removal of catheter in patients resuming therapeutic dosesg

Oral direct thrombin inhibitore

Hold day of procedure and 2 days prior (>48 h after last dose; hold 4 days if CrCl <50 mL/min)

Hold day of procedure and 2 days prior (>48 h after last dose; hold 4 days if CrCl <50 mL/min)

6-12 h after removal of catheter in patients starting prophylactic dosesh

≥24 h after removal of catheter in patients resuming therapeutic dosesi

a No high-quality data is available for oral direct factor Xa inhibitors or thrombin inhibitors.

b Applies to patients with normal renal function.

c Acenocoumarol and warfarin.

d Apixaban, edoxaban, and rivaroxaban.

e Dabigatran.

f Apixaban 2.5 mg bid, edoxaban 30 mg once daily, or rivaroxaban 10 mg once daily.

g Apixaban 5 mg bid, edoxaban 60 mg once daily, or rivaroxaban 20 mg once daily.

h Dabigatran 150-220 mg once daily.

i Dabigatran 110-150 mg bid.

aPTT, activated partial thromboplastin time; ASA, acetylsalicylic acid; bid, 2 times a day; CrCl, creatinine clearance; INR, international normalized ratio; IV, intravenous; LMWH, low-molecular-weight heparin; SC, subcutaneous; UFH, unfractionated heparin.