Guidelines for Antiplatelet and Anticoagulation Discontinuation before a Lumbar Puncture

by Joseph Esherick, M.D., FAAFP, FHM

This blog summarizes the guidelines by the European Society of Anesthesiology (ESA), the American Society of Regional Anesthesia (ASRA) and the Association of British Neurologists regarding the timing of antiplatelet and anticoagulation discontinuation before a lumbar puncture.  The following table is a summary of the recommendations of when to discontinue the medication before a lumbar puncture and when it is safe to resume the medication following a lumbar puncture.  The guidelines are geared toward spinal and epidural anesthesia but can be extrapolated to safety around a lumbar puncture:

*-Fibrinogen level should be >200 mg/dL before a lumbar puncture is performed

**-European Society of Anesthesiology (ESA) recommends a 48 hour wait time prior to neuraxial regional anesthesia for FXa inhibitors if CrCl>50 ml/min, but American Society of Regional Anesthesiologists (ASRA) recommends a 72 hour wait time for for FXa inhibitors if CrCl>50 ml/min.  ESA recommends a wait time of 72 hours for Dabigatran if CrCl>50 ml/min but ASRA recommends a wait time of 72 hours if CrCl>80 ml/min and 96 hours if CrCl 50-80 ml/min.

The Association of British Neurologists suggests a wait time of only 24-48 hours for apixaban and rivaroxaban and a wait time of 48-72 hours before dabigatran in patients with a normal renal function.  The recommendations above take the most conservative approach.

***-ESA and Association of British Neurologists recommend resumption of prophylactic or therapeutic enoxaparin/dalteparin no earlier than 4 hours after spinal puncture but ASRA recommends waiting at least 12 hours for prophylactic LWWH and at least 24 hours for therapeutic LMWH.  The mentioned time frame is the most conservative approach.

# - The range of resumption recommendations is 6-24 hours so the stated time in the table is the most conservative approach

Antiplatelets and anticoagulation before lumbar puncture

Sources:

1. Dodd, KC et al.  Periprocedural antithrombotic management for lumbar puncture:

Association of British Neurologists clinical guideline.  Pract Neurol 2018;18:436–446.

2. Layton KF et al.  Recommendations for Anticoagulated Patients Undergoing Image-Guided

Spinal Procedures.  Am J Neuroradiol 27:467–71

3.  Horlocker TT et al.  Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition).  Regional Anesthesia and Pain Medicine • Volume 43, Number 3,  263-309.