In patients who are likely to have an enhanced response to the drug, we recommend that a reduced dose be administered. (1B)

We recommend against the concurrent use of medications that affect other components of the clotting mechanisms and may increase the risk of bleeding complications for patients receiving oral anticoagulants and do so without influencing the INR. These medications include aspirin and other NSAIDs, thienopyridines, UFH, and LMWH. (1A)

Caution should be used when performing neuraxial techniques in patients recently discontinued from chronic warfarin therapy. In the first 1 to 3 days after discontinuation of warfarin therapy, the coagulation status (reflected primarily by factors II and X levels) may not be adequate for hemostasis despite a decrease in the INR (indicating a return of factor VII activity). Adequate levels of II, VII, IX, and X may not be present until the INR is within normal limits. We recommend that the anticoagulant therapy must be stopped (ideally 5 days prior to the planned procedure), and the INR normalized prior to initiation of neuraxial block. (1B)

With unanticipated administration with indwelling catheter, we suggest that dabigatran dosing be held for 34 to 36 hours or the dTT or ECT assessed before the catheter is removed. (2C)

We suggest that dabigatran be discontinued 120 hours in patients with a CrCl of 30 to 49 mL/min. Consider checking dTT or ECT if less than 120 hours. An acceptable level of residual dabigatran activity to proceed with neuraxial block remains undetermined. (2C)

We suggest that dabigatran be discontinued 96hours inpatients with a CrCl of 50to79mL/min. Consider checking dTT or ECT if less than 96 hours. An acceptable level of residual dabigatran activity to proceed with neuraxial block remains undetermined. (2C)

We suggest that dabigatran be discontinued 72hours in patients with a CrCl 80mL/min or greater. Consider checking dTT or ecarin clotting time (ECT) if less than 72 hours. An acceptable level of residual dabigatran activity to proceed with neuraxial block remains undetermined. (2C)

In patients receiving parenteral thrombin inhibitors, we recommend against the performance of neuraxial techniques. (2C)

In patients receiving C-dose warfarin therapy during epidural analgesia, we suggest that their INR be monitored on a daily basis. (2C)

In patients with an INR of greater than 3, we recommend that the warfarin dose be held or reduced in patients with indwelling neuraxial catheters. (1A)