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M. Fernández Hernández, N. Royuela-Martínez, Rocío Pérez Montes, A. Cuesta-García, B. González Mesones, D. Bouzas Pérez
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ABSTRACT Chronic pain is one of the leading causes of disability and functional impotence in today's society. The increased demand and complexity of infiltrations in chronic pain units increases every day. On the other hand, cardiovascular and cerebrovascular diseases are the ones that generate more morbi-mortality in our environment. Therefore, one of the problems that we face, prior to the infiltration, is the increase in the number of patients undergoing antiplatelet therapy (AAP) and/or anticoagulant therapy. The intake of antiplatelet agents or anticoagulants is of great concern in order to offer the patient an infiltration that affects the neuroege, deep myofascial infiltrations or deep blockages, since these procedures present a high hemorrhagic risk. The objective of this guide is to improve the quality and safety of antiaggregated and anticoagulated patients in order to receive an infiltration in the Pain Unit, as well as to avoid unnecessary referrals to other specialists. It is necessary to know the hemorrhagic risk of the procedures that we are going to carry out, but also the reasons why the patients are antiaggregated and anticoagulated and the safety limits for laying off each drug, not only to be aware of the consequences of an inadequate suspension of these treatments but to be able to establish an appropriate bridging therapy with. There are also certain circumstances that may increase the risk of procedural bleeding (alterations in the anatomy of the spine, multiple punctures, not using scopia, aspiration of blood after puncture...). This may influence the reintroduction of antiplatelet and anticoagulant therapy, which will be routinely reintroduced within 24 hours of infiltration. The anticoagulated patients are divided into two categories according to the infiltration to be performed: those who need to discontinue anticoagulants and to perform low molecular weight heparin (LMWH) bridge therapy and those who do not. Anti-vitamin K would be discontinued 3-5 days prior to infiltration. Direct Anticoagulants (DACOS) between 3-5 days, depending on the drug. LMWH bridging therapy would begin the day after the anticoagulant suspension. We contemplate special situations such as renal failure, which increases the safety intervals in the suspension of the drug for Direct Anticoagulants (DACOS) and requires variations in the pattern of LMWH for bridge therapy. The reintroduction of DACOS deserves special mention. This is done within 24 hours of the technique without the need to put LMWH simultaneously. In addition to the anti-vitamin K, an LMWH should be administered within 24 hours of infiltration, and during the next 5 days, until the INR is within the therapeutic range (control performed on an outpatient basis). Thus patients on acetyl salicylic acid treatment would have two categories: techniques that can be performed while maintaining ASA and those that do not. The remaining antiplatelet agents would have three options: techniques that need to be suspended to perform the techniques with different safety intervals for each drug, techniques in which it would be necessary to replace them with AAS based on thrombotic risk and those that would not require modification of the schedule. The acetyl salicylic acid must be interrupted: ASA 3-4 days, Clopidogrel 5-7 days, Prasugrel 4-6 days and Ticagrelor 3-5 days (Suspension in the lower number of the range will require a multidisciplinary assessment of the case). All recommendations have the objective of getting to the infiltration with drug levels low enough not to produce life-threatening bleeding and at the same time allow the therapeutic levels of each platelet or anticoagulant antiplatelet to be reached as fast possible after reintroduction. The replacement of antiagregant by LMWH at therapeutic doses is a possibility that is not completely validated. In patients with antiaggregant and anticoagulant the indications for each drug should be followed independently. In very specific situations such as double antiagging therapy or triple antitromotic therapy, it is best to wait until the thrombotic risk decreases. If infiltration/blocking is mandatory it is prudent to make a consensual multidisciplinar decision among the Hematology/Hemostasis, Cardiology and Pain Unity teams. At first, it was recommended to wait more than 12 months before suspending the double antiplatelet in patients with drug-eluting stents. However, new-generation stents allow modifications of this safety margin on which the interventional cardiologist should advise us. Special consideration is given to other drugs of habitual consumption, produce hemostasis alterations: NSAIDs, serotonin reuptake inhibitors (SSRIs). We recommend to request a complete coagulation study (AP, APTT, fibrinogen) for all patients who will undergo infiltrations of moderate or high bleeding risk prior to infiltration and the day of the same in those patients receiving anticoagulants.
