Preoperative. Based on labeling and surgical/ procedural experience, the recommended time interval between discontinuation of ticagrelor therapy is 5 to 7 days. (1C)

Thienopyridine therapy may be resumed immediately after needle placement/catheter removal, provided a loading dose of the drugs is not administered. If a loading dose is administered, we suggest a time interval of 6 hours between catheter removal and administration. (2C)

Neuraxial catheters should not be maintained with prasugrel or ticagrelor because of the rapid onset. However, because the antiplatelet effect is not immediate with ticlopidine and clopidogrel, neuraxial catheters may be maintained for 1 to 2 days, provided a loading dose of the antiplatelet agent is not administered. (2C)

Preoperative. Based on labeling and surgical/procedural experience, the recommended time interval between discontinuation of thienopyridine therapy and neuraxial blockade is 10 days for ticlopidine, 5 to 7 days for clopidogrel, and 7 to 10 days for prasugrel. (1C)

In patients receiving NSAIDS, we suggest caution in the performance of neuraxial techniques if the concurrent use of other medications affecting clotting mechanisms, such as other (non-NSAID) antiplatelet agents, oral anticoagulants, UFH, and LMWH, is anticipated in the early postoperative period because of the increased risk of bleeding complications. Cyclooxygenase 2 inhibitors have minimal effect on platelet function and should be considered in patients who require anti-inflammatory therapy in the presence of anticoagulation. (2C)

Nonsteroidal anti-inflammatory drugs appear to represent no added significant risk of the development of spinal hematoma in patients having epidural or spinal anesthesia. Nonsteroidal anti-inflammatory drugs (including aspirin) do not create a level of risk that will interfere with the performance of neuraxial blocks. In patients receiving these medications, we do not identify specific concerns as to the timing of single-injection or catheter techniques in relationship to the dosing of NSAIDs, postoperative monitoring, or the timing of neuraxial catheter removal. (1A)

In patients receiving an initial dose of warfarin prior to surgery, we suggest the INR should be checked prior to neuraxial block if the first dose was given more than 24 hours earlier or a second dose of oral anticoagulant has been administered. (2C)

In patients who are likely to have an enhanced response to the drug, we recommend that a reduced dose be administered. (1B)

We recommend against the concurrent use of medications that affect other components of the clotting mechanisms and may increase the risk of bleeding complications for patients receiving oral anticoagulants and do so without influencing the INR. These medications include aspirin and other NSAIDs, thienopyridines, UFH, and LMWH. (1A)

Caution should be used when performing neuraxial techniques in patients recently discontinued from chronic warfarin therapy. In the first 1 to 3 days after discontinuation of warfarin therapy, the coagulation status (reflected primarily by factors II and X levels) may not be adequate for hemostasis despite a decrease in the INR (indicating a return of factor VII activity). Adequate levels of II, VII, IX, and X may not be present until the INR is within normal limits. We recommend that the anticoagulant therapy must be stopped (ideally 5 days prior to the planned procedure), and the INR normalized prior to initiation of neuraxial block. (1B)