Pain pp 435-442 | Cite as


  • Selaiman A. NooriEmail author
  • Neel Mehta


The American Society of Regional Anesthesiologists and Pain Medicine (ASRA) recently published specific recommendations to reduce the risk of bleeding and neurological injury in patients on anticoagulant and antiplatelet medications. These guidelines stratify interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. Recommendations were evidence-based when available and pharmacology-driven otherwise. Although ASRA guidelines provide sound recommendations, a case-by-case approach must be taken to balance between bleeding and thromboembolism risk to safely manage pain interventions in patients on antiplatelet/anticoagulant therapy.


Anticoagulation Antiplatelets Antithrombotics Bleeding Hematoma Neuraxial Peripheral nerve blockade 


  1. 1.
    Tryba M. Epidural regional anesthesia and low molecular heparin: pro (German). Anasth Intesivmed Notfallmed Schmerzther. 1993;28(3):179–81.CrossRefGoogle Scholar
  2. 2.
    Deer T, Narouze S, Provenzano D, Pope J, Falowski S, Russo M, et al. The Neurostimulation Appropriateness Consensus Committee (NACC): recommendations on bleeding and coagulation management in neurostimulation devices. Neuromodulation. 2017;20:51–62.CrossRefGoogle Scholar
  3. 3.
    Patrono C, Ciabattoni G, Patrignani P, Pugliese F, Filabozzi P, Catella F, et al. Clinical pharmacology of platelet cyclooxygenase inhibition. Vasc Endovasc Surg. 1985;72(6):1177–84.Google Scholar
  4. 4.
    Gresele P, Momi S, Falcinelli E. Anti-platelet therapy: phosphodiesterase inhibitors. Br J Clin Pharmacol. 2011;72(4):634–46.CrossRefGoogle Scholar
  5. 5.
    Wallentin L. P2Y(12) inhibitors: differences in properties and mechanisms of action and potential consequences for clinical use. Eur Heart J. 2009;30(16):1964–77.CrossRefGoogle Scholar
  6. 6.
    Verhoef T, Redekop W, Daly A, van Schie R, de Boer A, Maitland-van der Zee A. Pharmacogenetic-guided dosing of coumarin anticoagulants: algorithms for warfarin, acenocoumarol and phenprocoumon. Br J Pharmacol. 2014;77(4):626–41.CrossRefGoogle Scholar
  7. 7.
    King C, Holley A, Jackson J, Shorr A, Moores L. Twice versus three times daily heparin dosing for thromboembolism prophylaxis in the general population: a metaanalysis. Chest. 2007;131(2):507–16.CrossRefGoogle Scholar
  8. 8.
    Hirsch J, Warkentin T, Shaughnessy S, Anand S, Halperin J, Raschke R, et al. Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety. Chest. 2001;119(1 Suppl):64S–94S.CrossRefGoogle Scholar
  9. 9.
    Tripodi A. The laboratory and the direct oral anticoagulants. Blood. 2013;121(20):4032–5.CrossRefGoogle Scholar
  10. 10.
    EINSTEIN Investigators, Bauersachs R, Berkowitz S, Brenner B, Buller H, Decousus H, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499–510.CrossRefGoogle Scholar
  11. 11.
    Frost C, Nepal S, Wang J, Schuster A, Byon W, Boyd R, et al. Safety, pharmacokinetics and pharmacodynamics of multiple oral doses of apixaban, a factor Xa inhibitor, in healthy subjects. Br J Clin Pharmacol. 2013;76(5):776–86.CrossRefGoogle Scholar
  12. 12.
    Dasgupta H, Blankenship J, Wood G, Frey C, Demko S, Menapace F. Thrombocytopenia complicating treatment with intravenous glycoprotein IIb/IIIa receptor inhibitors. A pooled analysis. Am Heart J. 2000;140(21):206–11.CrossRefGoogle Scholar
  13. 13.
    Jeong B, Kim S, Kim S, Kim J, Shin I, Yoon J. Use of serotonergic antidepressants and bleeding risk in patients undergoing surgery. Psychosomatics. 2014;55(3):213–20.CrossRefGoogle Scholar
  14. 14.
    Chan K, Lo A, Yeung J, Woo K. The effects of Danshen (Salvia miltiorrhiza) on warfarin pharmacodynamics and pharmacokinetics of warfarin enantiomers in rats. J Pharm Pharmacol. 1995;47(5):402–6.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Pain Management, Anesthesiology InstituteCleveland ClinicClevelandUSA
  2. 2.Division of Pain Medicine, Department of AnesthesiologyNew York-Presbyterian Hospital/Weill Cornell MedicineNew YorkUSA

Personalised recommendations