How long before a lumbar medial branch nerve radiofrequency ablation (or other equivalent pain procedure) should lovenox (enoxaparin) be stopped?

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I have various patients on lovenox/enoxaparin (or being bridged with lovenox) who need pain procedures as described above. ASRA guidelines call for the med to be stopped 12 hours prior for prophylactic dosing and 24 hours prior for therapeutic dosing [Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications]

They note that some prophylactic doses increase to 1.5mg/kg/day for obese patients. And I had a patient being bridged with 120mg/day. Considering this was a bridge I’m guessing this was a therapeutic dose but by the recommendation this could be a prophylactic dose, making it difficult to decide when to stop a dose like this?

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Our group had a similar problem. In your case I would consider that a therapeutic dose as well. Hence, I would stop it 24 hours prior to an injection.

Moreover, there are other “prophylactic doses” that are as high as 1mg/kg q12hrs. Additionally renal patients must have reduced dosing. [Lovenox (enoxaparin) dosing, indications, interactions, adverse effects, and more].

Considering the variability in dosing, the need for us to utilize staff to act as a second check for anticoagulation compliance, and the benefits of protocolized screening pre-procedure, we decided to have a blanket requirement to stop enoxaparin 24 hours prior to any of our neuraxial pain procedures. While there might be some cases that would be stopped earlier than needed, the additional 12 hours off their anticoagulant is probably a negligible risk. We do coordinate with the provider managing their anticoagulation to ensure this risk is acceptable on a case by case basis.

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