Plavix - The Neverending Story

[Mister Mxyzptlk]

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I seem to be getting a lot of clearances to hold Plavix for 5 days. When I say I need 7 days the cardiologists say their literature says 5 days. I tell them they are welcome to do the procedure after only 5 days if they want, but our literature says 7 days. In one case I just told the patient that they should ask their cardiologist to do the injection.

Anyone with more a productive approach?

 

[lobelsteve]

Dear Dr.

We are considering performing a Neuraxial Injection (ie: Epidural Injection, Nerve Root block, etc.) on your patient for the management of their pain; however, they are currently on the following anti-coagulation medication (listed below):

The American Society of Regional Anesthesia Guidelines on neuraxial procedures and anti-coagulation indicates that medication should be held as follows:

Coumadin (Warfarin) 5 days prior PT/INR can be checked in office
Clopidogrel (Plavix) 7 days prior We cannot stop if stented in last 12 months
Ticlodipine (Ticlid) 10 days prior
Effient (Prasugrel) 7 days prior
Pradaxa (Dabigatran) 2 – 4 days prior (Depends on CrCl)
Aggrenox 3 days prior, but should take baby aspirin those 3 days
Brilinta (Ticagrelor) 5 days prior

For Coumadin: While the non-spine related surgical literature suggests a goal INR of 1.5, the neuraxial data shows that epidural hematomas can still occur at that level of anti-coagulation. Therefore, my goal is INR <1.3 prior to any neuraxial procedure.

The patient may remain on Aspirin 81-325mg.

We would like to know if this medication can he held for this procedure? o YES o NO
Could this patient come off medication 2 to 4 times per year as needed? Please note, we do not do a series of injections and would repeat the procedure if effective every 3-6 months. o YES o NO

COMMENTS:

Patient:_______________________________ DOB:____________
Signed by: ____________________________ Date:____________


After completing this form, please fax it back to Medical Associates of North Georgia.

This form stolen and modified from Tenesma.
I don't ask the cardiologist how long to hold- I tell them 7 or nothing. If patients denied this from their cardiologist and it is unreasonable in my opinion- I offer to negotiate with the cardiologist or refer to a new cardiologist. No one feels HTN or heart disease, they feel pain. They already have had stenting or the MI and if their heart doctor wants tehm to suffer- there is one nearby who does not want them to have the stress and pain on their heart.

 

[OffPiste]

What are you all doing if on multiple antiplatelet agents?

If Plavix alone I hold 7 days
If Plavix+ASA I hold 10 (no literature backing, just being conservative and this is how we did things where I trained, have been thinking just going 7 days)
ASA no problems.

Still not sure how to best proceed if on multiple soft anticoagulants (the patient on ASA 81+ fish oil + garlic+ ginko, etc)

Pradaxa is tough because we do not always have a CrCl, so I just say 5 days

 

[lobelsteve]

What are you all doing if on multiple antiplatelet agents?

If Plavix alone I hold 7 days
If Plavix+ASA I hold 10 (no literature backing, just being conservative and this is how we did things where I trained, have been thinking just going 7 days)
ASA no problems.

Still not sure how to best proceed if on multiple soft anticoagulants (the patient on ASA 81+ fish oil + garlic+ ginko, etc)

Pradaxa is tough because we do not always have a CrCl, so I just say 5 days

Never hold ASA. Get bun/cr at visit ahead of procedure and then easy to know how long to hold pradaxa.

 

[Gauss]

what cards literature exists for anticoagulation and neuraxial procedures?? They usually ask me for the literature and I give them ASRA guidelines. They may be confusing ortho guidelines for total joints

 

[Mister Mxyzptlk]

Great form! I'm gonna steal that too.

 

[Jcm800]

Great form! I'm gonna steal that too.

I have been getting that also. Had cardiologist tell me that he will agree to 5 days, but any added risk if a we decide on 7 is on me...
His words.

 

[clubdeac]

Aggrenox only 3 days!? Is this the consensus on here? Wheres the literature on this?

 

[Jcm800]

Aggrenox only 3 days!? Is this the consensus on here? Wheres the literature on this?

we do 7 days, the life of the platelet. Like any anti-platelet except ticlid 10 days

 

[Tenesma]

aggrenox is 2-3 days for me too...

i never hold aspirin (unless they are taking 8 aspirin a day)...

 

[bedrock]

Aggrenox only 3 days!? Is this the consensus on here? Wheres the literature on this?

That's what I would think. Why not hold it for 7 days,...the life of the platelets?

 

[Mister Mxyzptlk]

Unlike ASA et al, dipyridamole's effects are reversible. 3 days should be plenty of time.

 

[bedrock]

Unlike ASA et al, dipyridamole's effects are reversible. 3 days should be plenty of time.

great, thanks

 

[clubdeac]

Unlike ASA et al, dipyridamole's effects are reversible. 3 days should be plenty of time.

Thanks MM!

 

[Ducttape]

Has anyone incorporated the P2Y12 assay into their practice?