Perioperative management of antiplatelet and anticoagulant therapy in patients undergoing interventional techniques: 2024 Updated Guidelines from the American Society of Interventional Pain Physicians (ASIPP)

Authors

Laxmaiah Manchikanti, Pain Management Centers of America, Paducah, KY and Evansville, IN; Departments of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY; LSU Health Science Center, New Orleans, LA.
Mahendra R. Sanapati, Pain Management Centers of America, Evansville, IN; Indiana University School of Medicine, Evansville, IN; Department of Anesthesiology, University of Louisville, Louisville, KY, USA.
Devi Nampiaparampil, Metropolis Pain Medicine, New York, NY; Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY, USA.
Byron J. Schneider, Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center.
Alexander Bautista, Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA.
Alan D. Kaye, Louisiana State University School of Medicine, Shreveport, LA.
Nebojsa Nick Knezevic, Advocate Health - MidwestFollow
Alaa Abd-Elsayed, UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI.
Annu Navani, Boomerang Healthcare, Walnut Creek, CA; Le Reve Regenerative Wellness, San Jose, CA.
Paul J. Christo, Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Standiford Helm Ii, Division of Pain Medicine, Department of Anesthesiology and Peri-Operative Care, University of California, Irvine, UCI Health Center for Pain and Wellness, Gottschalk Medical Plaza, Irvine, CA, USA.
Adam M. Kaye, Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA.
Jay Karri, Departments of Anesthesiology and Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
Vidyasagar Pampati, Pain Management Centers of America, Paducah, KY.
Sanjeeva Gupta, Department of Anesthesia, Pain Medicine, ICU and Sleep Medicine, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, West Yorkshire, UK.
Vivekanand A. Manocha, Department of Surgery, Wright State University School of Medicine, Dayton, OH; Beacon Orthopedics & Sports Medicine, Cincinnati, OH, USA.
Amol Soin, Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH.
Mayank Gupta, Kansas Pain Management and Neuroscience Research Center, LLC, Overland Park, KS; Department of Clinical Education, Kansas City University of Medicine and Biosciences, Kansas City, MO, USA.
Sanjay Bakshi, PRC Associates, MBM Management and Specialty Surgery Partners, Daytona Beach, FL, USA.
Christopher G. Gharibo, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY; Grossman School of Medicine, New York, NY.
Kenneth D. Candido, Thorek Memorial Hospital, Chicago, IL; University of Illinois College of Medicine-Chicago, Chicago, IL, USA.
Anjum Bux, Bux Pain Management, Lexington, KY, USA.
Anilkumar Vinayakan, Norton Pain Management Associates, Louisville, KY; Department of Anesthesiology, University of Louisville, Louisville, KY, USA.
Vinayak Belamkar, Witham Health Services, Frankfort, IN, USA.
Scott Stayner, Nura Pain Clinic, Minneapolis, MN.
Sairam Atluri, Tri-State Spine Care Institute, Cincinnati, OH.
Sara E. Nashi, TriHealth Physician Practices, Cincinnati, OH, USA.
Megan K. Applewhite, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA.
Chelsi Flanagan, Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA, USA.
Emiliya Rakhamimova, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.
et al

Recommended Citation

Manchikanti L, Sanapati MR, Nampiaparampil D, et al. Perioperative Management of Antiplatelet and Anticoagulant Therapy in Patients Undergoing Interventional Techniques: 2024 Updated Guidelines from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician. 2024;27(S6):S1-S94.

Affiliations

Advocate Illinois Masonic Medical Center

Abstract

Background:The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. Anticoagulants and antiplatelets target the clotting system, increasing the bleeding risk. However, discontinuation of anticoagulant or antiplatelet drugs exposes patients to thrombosis risk, which can lead to significant morbidity and mortality, especially in those with coronary artery or cerebrovascular disease. These guidelines summarize the current peer reviewed literature and develop consensus-based guidelines based on the best evidence synthesis for patients receiving anticoagulant and antiplatelet therapy during interventional procedures.

Study design:Review of the literature and development of guidelines based on best evidence synthesis.

Objectives:To provide a current and concise appraisal of the literature regarding the assessment of bleeding and thrombosis risk during interventional techniques for patients taking anticoagulant and/or antiplatelet medications.

Methods:Development of consensus guidelines based on best evidence synthesis included review of the literature on bleeding risks during interventional pain procedures, practice patterns, and perioperative management of anticoagulant and antiplatelet therapy. A multidisciplinary panel of experts developed methodology, risk stratification based on best evidence synthesis, and management of anticoagulant and antiplatelet therapy. It also included risk of cessation of anticoagulant and antiplatelet therapy based on a multitude of factors. Multiple data sources on bleeding risk, practice patterns, risk of thrombosis, and perioperative management of anticoagulant and antiplatelet therapy were identified. The relevant literature was identified through searches of multiple databases from 1966 through 2023. In the development of consensus statements and guidelines, we used a modified Delphi technique, which has been described to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approving specific guideline statements. Each panelist could suggest edits to the guideline statement wording and could suggest additional qualifying remarks or comments as to the implementation of the guideline in clinical practice to achieve consensus and for inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without primary conflict of interest.

Results:A total of 34 authors participated in the development of these guidelines. Of these, 29 participated in the voting process. A total of 20 recommendations were developed. Overall, 100% acceptance was obtained for 16 of 20 items. Total items were reduced to 18 with second and third round voting. The final results were 100% acceptance for 16 items (89%). There was disagreement for 2 statements (statements 6 and 7) and recommendations by 3 authors. These remaining 2 items had an acceptance of 94% and 89%. The disagreement and dissent were by Byron J. Schneider, MD, with recommendation that all transforaminals be classified into low risk, whereas Sanjeeva Gupta, MD, desired all transforaminals to be in intermediate risk. The second disagreement was related to Vivekanand A. Manocha, MD, recommending that cervical and thoracic transforaminal to be high risk procedures.Thus, with appropriate literature review, consensus-based statements were developed for the perioperative management of patients receiving anticoagulants and antiplatelets These included the following: estimation of the thromboembolic risk, estimation of bleeding risk, and determination of the timing of restarting of anticoagulant or antiplatelet therapy.Risk stratification was provided classifying the interventional techniques into three categories of low risk, moderate or intermediate risk, and high risk. Further, on multiple occasions in low risk and moderate or intermediate risk categories, recommendations were provided against cessation of anticoagulant or antiplatelet therapy.

Limitations:The continued paucity of literature with discordant recommendations.

Conclusion:Based on the review of available literature, published clinical guidelines, and recommendations, a multidisciplinary panel of experts presented guidelines in managing interventional techniques in patients on anticoagulant or antiplatelet therapy in the perioperative period. These guidelines provide a comprehensive assessment of classification of risk, appropriate recommendations, and recommendations based on the best available evidence.

Type

Article

PubMed ID

39133736