Antiplatelet and Anticoagulant Therapy in Interventional Pain Management

Managing antithrombotic and antiplatelet therapy is one of the common issues while performing interventional techniques to balance the bleeding risk and perioperative risk of thrombosis. There are myriad procedural guidelines on managing anticoagulant and antithrombotic therapy, even though most are based on evidence on retrospective studies and case reports. The risks of withholding antiplatelet therapy include cardiovascular, cerebrovascular, and peripheral vascular thrombosis which may result in catastrophic consequences including stroke and death. The risks of continuing antiplatelet therapy include bleeding and fatalities related to bleeding. Based on a comprehensive review of the literature, there is good evidence for the risk of a thromboembolic phenomenon in patients who stop antithrombotic therapy. There is also good evidence for the lack of necessity of stopping nonsteroidal anti-inflammatory drugs (NSAIDs), prior to performing interventional techniques. There is fair evidence that excessive bleeding, including epidural hematoma formation, may occur with interventional techniques when antithrombotic therapy is continued. There is fair evidence that the risk of a thromboembolic phenomenon is higher than the risk of epidural hematomas when antiplatelet therapy is stopped prior to interventional techniques. Consequently, except for procedures accessing the epidural space, antithrombotics may be continued. Standardized use of viscoelastic tests like thromboelastography or thromboelastometry or platelet function assay machines may more readily identify high-risk patients for potential bleeding complications while undergoing interventional pain procedures.