When to stop anticoagulation, anti-platelet aggregates, and non-steroidal anti-inflammatories (NSAIDs) prior to spine surgery
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, New York, and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience/Neurosurgery, Mineola, New York 11501, USA
DOI:10.25259/SNI-54-2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nancy E. Epstein. When to stop anticoagulation, anti-platelet aggregates, and non-steroidal anti-inflammatories (NSAIDs) prior to spine surgery. 26-Mar-2019;10:45
How to cite this URL: Nancy E. Epstein. When to stop anticoagulation, anti-platelet aggregates, and non-steroidal anti-inflammatories (NSAIDs) prior to spine surgery. 26-Mar-2019;10:45. Available from: http://surgicalneurologyint.com/surgicalint-articles/9239/
Background: Based upon a select review of the literature, in my opinion, spine surgeons, not just our medical/cardiological colleagues, need to know when to stop anticoagulant, anti-platelet aggregates, and non-steroidal anti-inflammatory (NSAIDs) medications prior to spine surgery to avoid perioperative bleeding complications.
Methods: Typically, medical/cardiological consultants, who “clear our patients” are not as aware as we are of the increased risks of perioperative bleeding if anticoagulant, anti-platelet, and NSAIDs are not stopped in a timely fashion prior to spine surgery (e.g. excessive intraoperative hemorrhage, and postoperative seromas, hematomas, and wound dehiscence).
Results: Different medications need to be discontinued at varying intervals prior to spinal operations. The anticoagulants include; Warfarin (stop at least 5 preoperative days), and Xa inhibitors (Eliquis (Apixaban: stop for 2 days) and Xarelto (Rivaroxaban: stop for 3 days)); note presently data vary. The anti-platelet aggregates include: Aspirin/Clopidogrel (stop >7-10 days preoperatively). The multiple NSAIDs should be stopped for varying intervals ranging from 1-10 days prior to spine surgery, and increase bleeding risks when combined with any of the anticoagulants or anti-platelet aggregates. NSAIDs (generic name/commercial names should be stopped preoperatively for at least; 1 day- Diclofenac (Voltaran), Ibuprofen (Advil, Motrin), Ketorolac (Toradol); 2 days- Etodolac (Lodine), Indomethacin (Indocin); 4-days-Meloxicam (Mobic) and Naproxen (Aleve, Naprosyn, Anaprox); 4 days- Nabumetone (Relafen); 6 days - Oxaprozin (Daypro); and 10 days- Piroxicam (Feldene).
Conclusions: Spine surgeons need to know when anti-platelet, anticoagulant, and NSAIDs therapies should be stopped prior to spine surgery to avoid perioperative bleeding complications.
Keywords: Multiple Cardiac Stents: Valve Replacement, Cardiac Myomectomy, Hypertrophic Cardiomyopathy, Plavix, Aspirin Therapy, Anticoagulation
In my opinion, we as spine surgeons, not just our medical/cardiological colleagues, need to know when anti-platelet, anticoagulant, and non-steroidal anti-inflammatory (NSAIDs) therapies should be stopped prior to spine surgery to avoid perioperative bleeding complications. This perspective summarizes the ideal timing for cessation of Aspirin/Clopidogrel (>7-10 days), Warfarin (at least 5 days), Xa inhibitors (Eliquis (Apixaban) and Xarelto (Rivaroxaban): for several days), and NSAIDS (varying from 1-10 days) prior to spine surgery to avoid postoperative seromas, hematomas, and wound dehiscence.
Guidelines for Cessation of Anticoagulation Prior to Spine Surgery
For those with cardiovascular disease on anticoagulation, when should therapy be stopped prior to spine surgery? Narouze et al. recommended that intravenous heparin be stopped 4 hours preoperatively.[
Guidelines for Cessation of Anti-Platelet Aspirin (ASA) Therapy Prior to Spine Surgery
Platelet Turnover Time
The hematologists tell us the typical platelet turnover time is 10 days for patients with normal bone marrow (i.e., data typically for younger patients). Nevertheless, many older patients may take longer to replace platelets as their bone marrow may become infiltrated with adipose tissue, prolonging platelet turnover time.
Physiology of Aspirin (ASA) Therapy
ASA irreversibly inactivates COX-1, blocks thromboxane production, platelet aggregation, and thus thrombosis. Narouze et al. confirmed an average 7-10 day duration of platelet function, which meant that approximately 50% of platelet function returned within 5 days of stopping ASA.[
Dosing and Levels of Oral Aspirin (ASA) Therapy
Narouze et al. defined different time parameters for cessation and restarting ASA.[
When to Stop Aspirin (ASA) Therapy Prior to Spine Surgery
Aspirin, the major leading anti-platelet aggreate, should typically be stopped at least 7-10 days prior to spine surgery. Park et al. (2013) evaluated 86 of 182 patients undergoing 1-2 level lumbar fusions; the control group of 96 patients (Group 0) were on no ASA, Group 1 patients stopped ASA 3 to 7 days preoperatively, while Group 2 patients discontinued ASA > 7 to 10 days preoperatively.[
Risk of ASA Withdrawal Syndrome
Acutely stopping anti-platelet therapies may, however, result in a transient hypercoagulation “withdrawal” syndrome, thereby increasing the preoperative/perioperative risks of cardiac stent thrombosis and/or embolism. Gerstein et al. (2012) observed that acutely stopping ASA perioperatively risked the “ASA withdrawal syndrome”, defined as platelet rebound, and an acute prothrombotic/hypercoagulable state increasing the risks of acute cardiovascular complications.[
Guidelines for Cessation of Anti-Platelet Clopidogrel Therapy Prior to Spine Surgery
Clopidogrel (75 mg po bid) blocks the ADP receptor P2Y12, and is typically used in conjunction with ASA (i.e., dual therapy) for prophylaxis in patients with cardiovascular/peripheral vascular disease, and/or cerebrovascular pathology.[
Clopidogrel requires approximately 24 hours to become effective, results in 50-60% platelet inhibition, and is reversed within 5-7 days following cessation of administration (controversial stopping points varies among specialists and types of procedures being performed).[
When to Stop NSAIDs Prior to Spine Surgery
There are different guidelines for when to stop the various NSAIDSs prior to surgery. The timing depends largely on the alternative half-lives of the various medications.[
NSAIDs Increased Bleeding Risks in Spine Surgery
NSAIDs increased bleeding risks for spine surgery, and should be discontinued for at least 5 half-lives preoperatively.[
In my opinion, spine surgeons, not just our medical/cardiological colleagues, need to know when anti-platelet, anticoagulant, and non-steroidal anti-inflammatory (NSAIDs) therapies should be stopped prior to spine surgery to avoid perioperative bleeding complications. Here we summarized the ideal timing for cessation of; Warfarin (at least 5 days), Xa inhibitors (Eliquis (Apixaban: 2 days) and Xarelto (Rivaroxaban; 3 days): Aspirin/Clopidogrel (>7-10 days), and NSAIDS (varying from 1-10 days) prior to spine surgery to avoid postoperative seromas, hematomas, and wound dehiscence.
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Conflicts of interest
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