New recommendations regarding practices for patients receiving antiplatelet and anticoagulant therapy before and after interventional spine and pain procedures were formulated by the American Society of Regional Anesthesia and Pain Medicine (ASRA),  in an update to the 2015 guidelines published in Regional Anesthesia and Pain Medicine.

On the basis of the availability of new antithrombotic medications and the publication of recent studies evaluating bleeding risks associated with specific interventional spine and pain procedures, the ASRA conducted extensive database searches in an effort to update related guidelines.

According to the guideline authors, there was a lack of large, well-designed studies evaluating bleeding risk for patients receiving interventional pain procedures.

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The authors noted that the “guidelines are based on limited clinical and animal data, and as such, the synthesis and interpretation of data by 1 group of experts may differ from conclusions by another set of equally qualified experts.”

The guidelines categorized pain procedures based on bleeding risk, from low-risk procedures (eg, peripheral nerve blocks) to high-risk procedures (eg, spinal cord stimulation trial and implant).

The guidelines recommended discontinuation of antiplatelet and anticoagulant therapy for high-risk procedures with suggestions for the time to discontinuation according to the pharmacokinetics of each drug. Low-risk and intermediate-risk procedures may not require discontinuation of anticoagulant and antiplatelet therapy, but the guidelines emphasized the importance of tailoring recommendations to each patient.

The recommendations also highlighted the importance of shared assessment, risk stratification, and management decisions between patients, interventional pain physicians, and prescribing physicians.In addition, a procedural anticoagulation management checklist was developed and included in the guidelines to assist with decision-making.

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The authors of the guidelines concluded that “It is expected that many practitioners might choose to post some of the tables and use these as their daily ‘cookbook’ for patients taking anticoagulant agents. While this is understood, we emphasize that these guidelines are not meant to be a standard of care; rather, we implore the reader to strive to understand the reasoning behind the guideline recommendations.”

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Narouze S, Benzon HT, Provenzano D, et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): 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 [published online December 22, 2017]. Reg Anesth Pain Med. doi: 10.1097/AAP.0000000000000700