Drug | Length of time to withhold before procedure | Time to restart after procedure | |
Antiplatelets | Aspirin | Continue | Continue |
ADP receptor antagonists | |||
Clopidogrel, ticagrelor, prasugrel | 7 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, eptifibatide | 4–8 hours | 24 hours | |
Abciximab | 48 hours | 24 hours | |
Other antiplatelets | |||
Dipyridamole | 24 hours | 6 hours | |
Cilostazol | 42 hours | 6 hours | |
Anticoagulation | Warfarin | Target 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 prophylaxis | 12 hours | 4 hours | |
LMWH treatment | 24 hours | 4 hours 24 hours if traumatic | |
Fondaparinux prophylaxis | 36 hours | 6–12 hours | |
Fondaparinux treatment | Avoid LP | Avoid LP | |
Intravenous unfractionated heparin | 4–6 hours APTT ratio≤1.4 | 1 hour | |
Direct oral anticoagulants | |||
Rivaroxaban Up to 20 mg/day | 24 hours | 6 hours | |
Apixaban 5 mg/day | 24 hours | 6 hours | |
Apixaban 20 mg/day | 24–48 hours | 6–24 hours | |
Dabigatran 150–300 mg/day | 48–72 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.