Table 2

Managing antithrombotics before lumbar puncture in patients with creatinine clearance ≥50 mL/min

DrugLength of time to withhold before procedureTime to restart after procedure
AntiplateletsAspirinContinueContinue
ADP receptor antagonists
 Clopidogrel, ticagrelor, prasugrel7 days
Consider aspirin bridging
Avoid LP or liaise with cardiology if drug-eluting stent <12 months or bare metal stent <1 months
6 hours
Glycoprotein IIa/IIIb receptor antagonists
 Tirofiban, eptifibatide4–8 hours24 hours
 Abciximab48 hours24 hours
Other antiplatelets
 Dipyridamole24 hours6 hours
 Cilostazol42 hours6 hours
Anticoagulation WarfarinTarget INR≤1.4
Elective: withhold for 5 days and then check INR the day of the procedure. If high risk for thrombosis* then use LMWH bridging
Urgent: liaise with haematology
12 hours
 LMWH prophylaxis12 hours4 hours
 LMWH treatment24 hours4 hours
24 hours if traumatic
 Fondaparinux prophylaxis36 hours6–12 hours
 Fondaparinux treatmentAvoid LPAvoid LP
 Intravenous unfractionated heparin4–6 hours
APTT ratio≤1.4
1 hour
Direct oral anticoagulants
 Rivaroxaban
 Up to 20 mg/day
24 hours6 hours
 Apixaban
 5 mg/day
24 hours6 hours
 Apixaban
 20 mg/day
24–48 hours6–24 hours
 Dabigatran 150–300 mg/day48–72 hours
Contraindicated according to manufacturer
6 hours
Contraindicated according to manufacturer
  • *High-risk conditions requiring treatment dose LMWH bridging: patients with a venous thromboembolism within the previous 3 months, or previous venous thromboembolism while on therapeutic anticoagulation, those with mechanical heart valves other than those with a bileaflet aortic valve and no other risk factors, those with atrial fibrillation and previous stroke or transient ischaemic attack in the past 3 months, or previous stroke/transient ischaemic attack and CHA2DS2-VASc score of ≥3.

  • Intermediate-risk conditions requiring prophylactic dose LMWH bridging: venous thromboembolism>3 months ago.

  • APTT, activated partial thromboplastin time; INR, international normalised ratio; LMWH, low-molecular-weight heparin; LP, lumbar puncture.