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Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline
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  • Published on: 16 November 2018
    Re: Lumbar puncture on Direct Oral Anticoagulants (DOACs): a novel, emerging perspective
    • Katherine Dodd, Neurology Registrar Salford Royal NHS Foundation Trust
    • Other Contributors:
      • Hedley Emsley, MD
      • Michael Desborough, MD
      • Suresh Chhetri, MD

    We are very grateful to Dr Rota and colleagues for their interest in our guideline.

    In essence, we agree that international consensus on DOAC level measurement and cut-off levels would be welcome.

    The experience reported by Dr Rota and colleagues of their use of idarucizumab for emergency reversal of dabigatran prior to lumbar puncture is reassuring. Our guideline refers to the need to consult a haematologist prior to administration; however, a guideline is for guidance and we recognise that locally agreed protocols may vary. Likewise, the timings mentioned in the guideline relating to the safe reinitiation of DOACs are by necessity pragmatic. Further evidence in this area will of course be very welcome to further inform practice.

    Conflict of Interest:
    None declared.
  • Published on: 16 November 2018
    Lumbar puncture on Direct Oral Anticoagulants (DOACs): a novel, emerging perspective
    • Eugenia Rota, Neurologist, Chief of the Neurology Unit San Giacomo Hospital, Novi Ligure, AL, Italy
    • Other Contributors:
      • Sergio Agosti, Cardiologist
      • Roberta Risso, Internal Medicine
      • Nicola Morelli, Neurologist, Radiologist

    Dear Editor,
    We read the article by Dodd et al. (2018) [1] with great interest. The authors provide evidence-based recommendations for the periprocedural management of antithrombotic and anticoagulant treatment in patients who require a lumbar puncture (LP). Indeed, this is a very relevant practical point for neurologists, above all when an urgent diagnostic LP is mandatory to rule out an infectious disease of the central nervous system, or a subarachnoid hemorrhage. The recommendations on adjustment/reversal of warfarin for patients on oral anticoagulants, who require LP, are well known, i.e. long-term LP allowed if INR is < 1.4. Whilst the question of how to manage patients on Direct Oral Anticoagulants (DOACS), a relatively novel pharmacological class, is also to be answered. Dodd et al’s article [1] reports that if a non-urgent LP has to be carried out he these patients, current recommendations vary among different advisory bodies about the time lapse necessary for DOAC withdrawal before the LP, depending on the renal function. The interesting possibility of measuring the drug-specific levels, so as to estimate the anticoagulant effect of a DOAC, is also mentioned, although the authors are of the opinion that routine testing before the LP is not necessary. [1]
    We believe that this is a crucial point, above all in the case of an urgent or emergent LP. Indeed, in our experience, when available, drug-specific levels can be obtained quickly and guide the cl...

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    Conflict of Interest:
    None declared.

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