1. 2024;27;S1-S94Perioperative Management of Antiplatelet and Anticoagulant Therapy in Patients Undergoing Interventional Techniques: 2024 Updated Guidelines from the American Society of Interventional Pain Physicians (ASIPP)
   Guidelines
   Laxmaiah Manchikanti, MD, Mahendra R. Sanapati, MD, Devi Nampiaparampil, MD, Byron J. Schneider, MD, Alexander Bautista, MD, Alan D. Kaye, MD, PhD, Nebojsa Nick Knezevic, MD, PhD, Alaa Abd-Elsayed, MD, Annu Navani, MD, Paul J. Christo, MD, Standiford Helm II, MD, Adam M. Kaye, PharmD, Jay Karri, MD, Vidyasagar Pampati, MSc, Sanjeeva Gupta, MD, Vivekanand A. Manocha, MD, Amol Soin, MD, Mayank Gupta, MD, Sanjay Bakshi, MD, Christopher G. Gharibo, MD, Kenneth D. Candido, MD, Anjum Bux, MD, Anilkumar Vinayakan, MD, Vinayak Belamkar, MD, Scott Stayner, MD, PhD, Sairam Atluri, MD, Sara E. Nashi, MD, Megan K. Applewhite, MD, Chelsi Flanagan, DO, Emiliya Rakhamimova, BA, Gerard Limerick, MD, PhD, Kunj G. Patel, MD, Sierra Willeford, DO, and Joshua A. Hirsch, MD.

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.

KEY WORDS: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antiplatelet therapy, interventional techniques, safety precautions, pain

DISCLAIMER: These guidelines are crafted from the most up-to-date evidence and are not intended as rigid treatment mandates. Given the evolving nature of scientific evidence, this document does not aim to establish a definitive “standard of care.”