New Guidelines and App for Antiplatelet and Anticoagulant Therapy During Interventional Spine and Pain Procedures

Peer Reviewed

Updated guidelines and a new app (ASRA Coags 2.0) help guide clinical decision-making on when to stop antiplatelet and anticoagulant therapies in patients undergoing interventional spine and pain procedures to avoid serious bleeding, and when to restart the agents after the procedures. In addition to inclusion of newly approved antigcoagulants/antiplatelets (eg, apixaban, betrixaban, dabigatran, edoxaban, rivaroxaban) and data from recent clinical trials specific to interventional spine and pain procedures, other noteworthy updates from the 2015 guidelines include reclassification of lumbar facet injections to the low-risk group and inclusion of the recently approved minimally-invasive peripheral nerve stimulation to the low-risk group.
anticoagulant rivaroxaban chemical formulationNew clinical practice guideline includes newly approved antigcoagulants/ antiplatelets, such as rivaroxaban.The guidelines, which were published in the April issue of Regional Anesthesia and Pain Medicine, were a collaborative effort led by the American Society of Regional Anesthesia and Pain Medicine. The final recommendations were endorsed by the European Society of Regional Anaesthesia and Pain Therapy, American Academy of Pain Medicine, International Neuromodulation Society, the North American Neuromodulation Society, and World Institute of Pain.

“Physicians should be familiar with the decision-making process and the risk of bleeding from these medications compared to the risk of cardiovascular or cerebrovascular complications from stopping these medications,” said guideline lead author Samer Narouze, MD, PhD, Clinical Professor of Anesthesiology and Neurological Surgery, and Chairman of the Center for Pain Medicine at Western Reserve Hospital, Cuyahoga Falls, OH (@NarouzeMD).

Risk Stratification by Interventional Procedures
The guidelines categorized pain procedures based on bleeding risk, from low-risk procedures (eg, peripheral nerve blocks) with no discontinuation of anticoagulant needed for most agents, to high-risk procedures (eg, spinal cord stimulation lead placement and vertebral augmentation) that require anticoagulant discontinuation. Even among low-risk procedures, certain agents (eg, heparin, enoxaparin, dalteparin, and fibrinolytic agents) should be discontinued 6 to 48 hours before the procedures and others (eg, coumadin and acenocoumarol) require shared assessment and risk stratification.

Patients with high risk of bleeding (eg, old age, history of bleeding tendency, concurrent uses of other anticoagulants/antiplatelets, liver cirrhosis or advanced liver disease, and advanced renal disease) undergoing low- or intermediate-risk procedures should be treated as intermediate or high risk, respectively, according to the recommendations. The guidelines provide a comprehensive table listing when to stop and restart an agent (if necessary) each anticoagulant and antiplatelet agent based on the risk categories. In addition, a patient-specific procedural anticoagulation management checklist is included.
Narouze ImageFigure. Pain procedures grouped by potential risk for serious bleeding. Source: Narouze et al. Reg Anesth Pain Med. 2018;43(3):225-262.

Figure. Pain procedures grouped by potential risk for serious bleeding.
Source: Narouze et al. Reg Anesth Pain Med. 2018;43(3):225-262.
*Patients with high risk of bleeding (eg, old age, history of bleeding tendency, concurrent uses of other anticoagulants/antiplatelets, liver cirrhosis or advanced liver disease, and advanced renal disease) undergoing low- or intermediate-risk procedures should be treated as intermediate or high risk, respectively.
Peripheral neuromodulation is low to intermediate risk, depending on the location of the targeted nerve in relation to critical vessels and the invasiveness of the procedure.

A procedure classified as “high risk” is not necessarily risky, but rather the categories constitute a relative risk, rather than absolute risk, the guidelines note. In addition, the guidelines "are based on limited clinical and animal data,” and are not intended to define the standard of care, according to the paper. The guidelines will be updated periodically in the future.

Clinical Application of the Guidelines
When applying the guidelines into clinical practice, Dr. Narouze suggested first determining whether the planned injection/procedure falls under low, intermediate, or high-risk category for bleeding and then following the recommendations for each drug. In addition, the App ASRA Coags 2.0, was recently created based on the guidelines (https://www.asra.com/page/150/asra-apps) and can be used as a reference tool to match spine/pain interventional procedures with antiplatelets and anticoagulants, Dr. Narouze told SpineUniverse.

“In terms of patient education, patients should be aware of the potential bleeding risk associated with continuing anticoagulant/antiplatelet medications versus stopping these medications, possibly exposing patients to an increased risk of stroke or heart attack depending on the condition underlying prescription of these agents,” Dr. Narouze said.

COMMENTARY
Stuart Kahn, MD
Associate Professor of Orthopaedics and Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai

The main takeaway point is that these guidelines are just that, guidelines. Each physician and patient must come up with a plan that is right for each intervention, based on the individual patient’s risk. The risk stratification spreadsheet and statements in the updated guidelines are very apropos.

Though each physician must take into consideration each patient’s individual situation, as the risk stratification component of the guidelines alludes to, each physician too must make a decision based on the experiences of the individual patient and of their referring physicians. The thought of performing an interventional spine procedure for some patients taking an anticoagulant agent, even with the data from recent studies showing that the risks of discontinuing an anticoagulant may be greater than continuing it, is frightening. In addition, the community physicians may not be up to speed with the current literature, and therefore, disapproving of continuing antiplatelet/anticoagulant therapy during interventional spine and pain procedures. It is up to the interventionist to teach their colleagues about the latest data.

Lingering in the minds of many interventionists is the fear that a patient may have an epidural hematoma and neurologic sequelae after an interventional procedure is performed while the patient remained on anticoagulants deemed to be safe for use during low-risk procedures. Their sense of moral pain and responsibility may be overwhelming. Their legal liability, despite following the most up-to-date medical guidelines and current literature, may be far greater as well.

In summary, each medical decision that a practitioner makes for and with their patient is important and needs to be considered individually with the use of up-to-date medical guidelines and a patient’s individual health history and risks in mind.

Disclosures
Dr. Narouze has no relevant disclosures.
Dr. Kahn has no relevant disclosures.

Updated on: 06/07/18
Continue Reading
Overcoming Barriers to Non-surgical Treatment for Lumbar Spinal Stenosis
Samer Narouze, MD, PhD
Chairman, Center for Pain Medicine
Western Reserve Hospital
Cuyahoga Falls, OH
Stuart B Kahn, MD
Director, Interventional Physiatry
Orthopaedic Spine Center
Mount Sinai Medical Center
New York, NY
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