Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Background: Interventional pain management involves diagnosis and treatment of chronicpain. This specialty utilizes minimally invasive procedures to target therapeutics to the centralnervous system and the spinal column. A subset of patients encountered in interventional pain aremedicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since thesedrugs target the clotting system, bleeding risk is a consideration accompanying interventionalprocedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposesunderlying thrombosis risk, which can lead to significant morbidity and mortality especially in thosewith coronary artery or cerebrovascular disease. This review summarizes the literature and providesguidelines based on best evidence for patients receiving anti-clotting therapy during interventionalpain procedures.Study Design: Best evidence synthesis.Objective: To provide a current and concise appraisal of the literature regarding an assessmentof the bleeding risk during interventional techniques for patients taking anticoagulant and/orantithrombotic medications.Methods: A review of the available literature published on bleeding risk during interventional painprocedures, practice patterns and perioperative management of anticoagulant and antithrombotictherapy was conducted. Data sources included relevant literature identified through searches ofEMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographiesof known primary and review articles.Results:1. There is good evidence for risk stratification by categorizing multiple interventionaltechniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors.2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy.3. There is good evidence supporting discontinuation of low dose aspirin for high riskand moderate risk procedures for at least 3 days, and there is moderate evidence thatthese may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran(Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin,apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux(Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety.5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection,rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunctionto avoid neurological sequelae.6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can beinstituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24hours before the pain procedure.7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks aresignificant.8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosingspondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleedingobserved during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma.9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine],cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 daysprior to undergoing interventional techniques of moderate and high risk.10. There is fair evidence to make shared decision making between the patient and the treating physicians with thetreating physician and to consider all the appropriate risks associated with continuation or discontinuation ofantithrombotic or anticoagulant therapy.11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours afterthe interventional procedure is performed.12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epiduralhematomas.13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin,for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebralprotective effect.Limitations: The continued paucity of the literature with discordant recommendations.Conclusion: Based on the survey of current literature, and published clinical guidelines, recommendations for patients presentingwith ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis ofeach patient and the risk-benefit analysis of intervention.Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventionaltechniques, safety precautions, pain