MSKCC Neuraxial Analgesia Anticoagulation Guidelines

Surgery Date

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💊

COX Inhibitors (Antiplatelet)

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
NSAIDS / ASA / Celebrex		No contraindication	No contraindication	No contraindication	No contraindication

🔄

P2Y12 / ADP Pathway Inhibitors (Antiplatelet)

Medication	Before Placement	During	Before Removal	After Removal
ASA & Dipyridamole (Aggrenox) (Mixed MOA: COX + PDE Inhibitor)	held 5 days (120hrs)	hold, or remove EPI	hold	6 hours after removal
Plavix (Clopidogrel)	held 7 days (168hrs)	hold, or remove EPI	hold	6 hours after removal
Prasugrel (Effient)	held 7 days (192hrs)	hold, or remove EPI	hold	6 hours after removal
Ticagrelor (Brillinta)	held 5 days (120hrs)	hold, or remove EPI	hold	24 hours after removal
Ticlid (Ticlopidine)	held 10 days (240hrs)	hold, or remove EPI	hold	6 hours after removal

🛑

Phosphodiesterase Inhibitors (Antiplatelet)

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
Pletal (Cilostazol)		held 2 days (48hrs)	hold, or remove EPI	hold	6 hours after removal

🍃

Vitamin K Antagonist (Anticoagulant)

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
Coumadin (Warfarin)		hold 5 days and INR < 1.4	hold, or remove EPI	hold until INR < 1.4	6 hours after removal

💉

Indirect Thrombin/Factor Xa Inhibitors (Heparins)

Medication	Before Placement	During	Before Removal	After Removal
Heparin (IV therapeutic) (Unfractionated)	6 hours and normalized PTT	1 hour after placement	4h held & normal PTT	1 hour after removal
Heparin SC (prophylaxis) (Unfractionated)	4 hours	1 hour after placement	4 hours	1 hr after removal
LMWH (BID prophylaxis) (e.g., Enoxaparin)	held 24 hours	Remove catheter before dosing	held 24 hours	4 hours after removal
LMWH (QD prophylaxis) (e.g., Enoxaparin)	held 24 hours	Start 12 hours post-placement	held 24 hours	4 hours after removal
LMWH (therapeutic) (e.g., Enoxaparin)	held 24 hours	Remove catheter before dosing	held 24 hours	4 hours after removal

⚠️

Indirect Factor Xa Inhibitor (Synthetic Pentasaccharide)

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
Fondaparinux (Arixtra)		AVOID	AVOID	AVOID (or hold 3 days min)	?12 hours after removal

🔶

Direct Factor Xa Inhibitors (DOACs)

Medication	Before Placement	During	Before Removal	After Removal
Apixaban (Eliquis)	held 3 days (72hrs)	hold, or remove EPI	hold 3 days	6 hours after removal
Edoxaban (Savaysa)	held 3 days (72hrs)	hold, or remove EPI	held 3 days	give 6 hour after removal
Rivaroxaban (Xarelto)	held 3 days (72hrs)	hold, or remove EPI	held 3 days	give 6 hour after removal

🧪

Direct Thrombin Inhibitors (Anticoagulant)

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
Argatroban Dabigatran (Pradaxa) Hirudins		Hold 5 days (Dabigatran) Check PTT/TT (others vary)	hold, or remove EPI	hold	6 hours after removal

⛔

Fibrinolytics / Thrombolytics

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
Thrombolytics (e.g., alteplase, tPA)		Contraindicated	Contraindicated	Contraindicated	Contraindicated

🧬

BTK Inhibitors (Oncology Agents with Antiplatelet Effect)

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
BTK Inhibitors Ibrutinib (IMBRUVICA) Acalabrutinib (CALQUENCE) Zanubrutinib (BRUKINSA)		held 7 days (168hrs) (Range 2-7d, use conservative)	hold, or remove EPI	hold, or remove EPI	Consult Provider

🌱

VEGF/Tyrosine Kinase Inhibitors (Anti-angiogenesis/Antiplatelet Effect)

Medication	Before Placement	During	Before Removal	After Removal
Aflibercept (Eylea/Zaltrap)	4-6 weeks	Consult Provider	Consult Provider	Consult Provider
Axitinib (Inlyta) (TKI)	1-2 weeks	Consult Provider	Consult Provider	Consult Provider
Bevacizumab (Avastin)	4-6 weeks	Consult Provider	Consult Provider	Consult Provider
Cabozantinib (Cabometyx/Cometriq) (TKI with VEGF Inhibitor effect)	2-4 weeks	Consult Provider	Consult Provider	Consult Provider
Levatinib (Lenvima)	1-2 weeks	Consult Provider	Consult Provider	Consult Provider
Pazopanib (Votrient) (TKI)	1-2 weeks	Consult Provider	Consult Provider	Consult Provider
Pegaptanib (Macugen)	2-4 weeks	Consult Provider	Consult Provider	Consult Provider
Ramucirumab (Cyramza)	4-6 weeks	Consult Provider	Consult Provider	Consult Provider
Sorafenib (Nexavar)	1-2 weeks	Consult Provider	Consult Provider	Consult Provider

☢️

DNA Repair Damage Agents

Medication	Last Dose	Before Placement	During	Before Removal	After Removal
Bleomycin		1-2 weeks	Consult Provider	Consult Provider	Consult Provider

Guideline times assume normal renal and hepatic function. Adjustments may be necessary otherwise. Always confirm with institutional policy and clinical judgment. "*" in image data may denote specific considerations not fully captured here.

Epidural/Spinal Placement: INR < 1.4 PTT < 42 Platelets > 100,000 No known coagulopathy

Nerve Block Placement: INR < 1.4 PTT < 42 Platelets > 50,000 No known coagulopathy

INR ≥ 1.5 PTT ≥ 42 Platelets < 80,000 Known coagulopathy Receiving therapeutic anticoagulation