MSKCC Neuraxial Analgesia Anticoagulation Guidelines

Last dose date updates automatically
💊
COX Inhibitors (Antiplatelet)
Medication Last Dose Before Placement During Before Removal After Removal
NSAIDS / ASA / Celebrex No contraindication No contraindication No contraindication No contraindication

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

🔄
P2Y12 / ADP Pathway Inhibitors (Antiplatelet)
Medication Last Dose 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

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Plavix (Clopidogrel) held 7 days (168hrs) hold, or remove EPI hold 6 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Prasugrel (Effient) held 7 days (192hrs) hold, or remove EPI hold 6 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Ticagrelor (Brillinta) held 5 days (120hrs) hold, or remove EPI hold 24 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Ticlid (Ticlopidine) held 10 days (240hrs) hold, or remove EPI hold 6 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

🛑
Phosphodiesterase Inhibitors (Antiplatelet)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Pletal (Cilostazol) held 2 days (48hrs) hold, or remove EPI hold 6 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

🍃
Vitamin K Antagonist (Anticoagulant)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Coumadin (Warfarin) hold 5 days and INR < 1.4 hold, or remove EPI hold until INR < 1.4 6 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

💉
Indirect Thrombin/Factor Xa Inhibitors (Heparins)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Heparin (IV therapeutic)
(Unfractionated)		 6 hours and normalized PTT 1 hour after placement 4h held & normal PTT 1 hour after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Heparin SC (prophylaxis)
(Unfractionated)		 4 hours 1 hour after placement 4 hours 1 hr after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

LMWH (BID prophylaxis)
(e.g., Enoxaparin)		 held 24 hours Remove catheter before dosing held 24 hours 4 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

LMWH (QD prophylaxis)
(e.g., Enoxaparin)		 held 24 hours Start 12 hours post-placement held 24 hours 4 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

LMWH (therapeutic)
(e.g., Enoxaparin)		 held 24 hours Remove catheter before dosing held 24 hours 4 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

⚠️
Indirect Factor Xa Inhibitor (Synthetic Pentasaccharide)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Fondaparinux (Arixtra) AVOID AVOID AVOID (or hold 3 days min) ?12 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

🔶
Direct Factor Xa Inhibitors (DOACs)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Apixaban (Eliquis) held 3 days (72hrs) hold, or remove EPI hold 3 days 6 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Edoxaban (Savaysa) held 3 days (72hrs) hold, or remove EPI held 3 days give 6 hour after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Rivaroxaban (Xarelto) held 3 days (72hrs) hold, or remove EPI held 3 days give 6 hour after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

🧪
Direct Thrombin Inhibitors (Anticoagulant)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Argatroban
Dabigatran (Pradaxa)
Hirudins		 Hold 5 days (Dabigatran)
Check PTT/TT (others vary)		 hold, or remove EPI hold 6 hours after removal

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

⛔
Fibrinolytics / Thrombolytics
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Thrombolytics
(e.g., alteplase, tPA)		 Contraindicated Contraindicated Contraindicated Contraindicated

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

🧬
BTK Inhibitors (Oncology Agents with Antiplatelet Effect)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter 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

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

🌱
VEGF/Tyrosine Kinase Inhibitors (Anti-angiogenesis/Antiplatelet Effect)
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Aflibercept (Eylea/Zaltrap) 4-6 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Axitinib (Inlyta)
(TKI)		 1-2 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Bevacizumab (Avastin) 4-6 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Cabozantinib (Cabometyx/Cometriq)
(TKI with VEGF Inhibitor effect)		 2-4 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Levatinib (Lenvima) 1-2 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Pazopanib (Votrient)
(TKI)		 1-2 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Pegaptanib (Macugen) 2-4 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Ramucirumab (Cyramza) 4-6 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

Sorafenib (Nexavar) 1-2 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

☢️
DNA Repair Damage Agents
MedicationLast DoseBefore PlacementDuringBefore RemovalAfter Removal
Bleomycin 1-2 weeks Consult Provider Consult Provider Consult Provider

Last Dose:

Before Placement:

During:

Before Removal:

After Removal:

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.

Coagulation Targets for Neuraxial Procedures

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

Consult Attending for Catheter Removal if:

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