Interventional Spine Trainer

medications

Anticoagulation Hold Times by Procedure Risk

Medication	Peripheral (MBB, trigger point, peripheral joint)	Intermediate (TFESI, facet, SIJ)	Neuraxial (interlaminar, SCS lead)
Aspirin81-325 mg daily	Continue	Continue	Continue
Clopidogrel (Plavix)75 mg daily	Continue or hold 1-2d	Hold 5-7 days	Hold 7 days
Warfarin (Coumadin)INR target 2-3	Continue (check INR)	Hold 5d, INR ≤1.5	Hold 5d, INR ≤1.5
Apixaban (Eliquis)5 mg BID	Continue	Hold 24-48h	Hold 3 days (72h)
Rivaroxaban (Xarelto)20 mg daily	Continue	Hold 24-48h	Hold 3 days (72h)
Dabigatran (Pradaxa)150 mg BID	Continue	Hold 4 days (CrCl >50)	Hold 4-5 days (CrCl >50); 6 days if CrCl <50
Enoxaparin (prophylactic)40 mg daily	Continue	Hold 12h	Hold 12h
Enoxaparin (therapeutic)1 mg/kg BID	Continue or hold 12h	Hold 24h	Hold 24h
Heparin IVContinuous infusion	Continue	Hold 4-6h, check aPTT	Hold 4-6h, norm aPTT

Notes

1. Green = generally safe to continue. Yellow = case-by-case, coordinate with prescriber. Red = must hold.
2. Dabigatran: hold 4-5 days for high-bleeding-risk procedures with CrCl >=50 mL/min; extend to 6 days if CrCl <50 mL/min, per ASRA 2018 (Narouze) guidelines.
3. DOACs: no reliable coagulation test confirms clearance. Anti-Xa levels may help for factor Xa inhibitors.
4. Never hold P2Y12 inhibitors within 6 months of bare-metal stent or 12 months of drug-eluting stent without cardiology approval
5. Bridging is NOT recommended for DOACs. For warfarin patients with mechanical valves, discuss bridging with prescriber.
6. Resume anticoagulation 24h post-procedure if no complications. Resume LMWH 24h after neuraxial.
7. The thromboembolic risk of holding medication often exceeds bleeding risk for peripheral procedures (IPSIS Task Force).

Source: ASRA 2024, SIS/ASIPP Guidelines, IPSIS Task Force | Updated: 2026-04-03