How long before a spinal or epidural should a DOAC be stopped?

ASRA 4th edition suggests holding rivaroxaban, apixaban and edoxaban for 72 hours before neuraxial puncture or catheter manipulation, and dabigatran for 72–120 hours depending on creatinine clearance. Restart is typically 6 hours after the needle or catheter. Renal impairment prolongs all of these. Confirm CrCl and the source guideline.

Is aspirin a contraindication to neuraxial blockade?

Low-dose aspirin as monotherapy is not a contraindication and does not require an additional waiting period. Risk rises when aspirin is combined with another anticoagulant or antiplatelet (e.g. clopidogrel), which should be timed on its own interval.

What is the interval for prophylactic versus therapeutic LMWH?

Prophylactic-dose LMWH: hold 12 hours before the block and restart 12 hours after (and at least 4 hours after catheter removal). Therapeutic-dose LMWH: hold 24 hours before and restart 24 hours after. CrCl below 30 markedly prolongs exposure. Extend the interval or avoid neuraxial technique.

For Professionals · Quick reference

ASRA anticoagulation & neuraxial timing

Hold-before and restart-after intervals for neuraxial blockade and deep peripheral blocks, across antiplatelets, heparins, warfarin and the DOACs: with the renal caveats that change them. Search an agent or print for the block list.

Medically reviewed by Dr. Saurabh Shukla, Anesthesiologist · Last updated August 5, 2026

Antiplatelet agents 11

Aspirin (low-dose, monotherapy)

Hold before

No restriction, may continue

Restart after

No restriction

NSAIDs (monotherapy)

Hold before

No restriction, may continue

Restart after

No restriction

▲ Clopidogrel

Hold before

5–7 days

Restart after

Resume after catheter removed (loading dose ≥24 h; maintenance immediately)

▲ Prasugrel

Hold before

7–10 days

Restart after

≥6 h after catheter removal

▲ Ticagrelor

Hold before

5–7 days

Restart after

≥6 h after catheter removal

▲ Ticlopidine

Hold before

10 days

Restart after

After catheter removal

Cilostazol

Hold before

2 days

Restart after

After catheter removal

Dipyridamole (extended-release)

Hold before

24 h

Restart after

After catheter removal

▲ GP IIb/IIIa, abciximab

Caveat: Avoid neuraxial within ~4 wk of these agents

Hold before

24–48 h (until platelet function recovers)

Restart after

—

▲ GP IIb/IIIa, eptifibatide / tirofiban

Caveat: Reduced clearance in renal impairment

Hold before

4–8 h

Restart after

—

Cangrelor

Hold before

3 h

Restart after

—

Unfractionated heparin 2

UFH, subcutaneous prophylaxis (≤5000 U BID/TID)

Caveat: Higher SC doses (>5000 U/dose or >15000 U/day): treat as therapeutic

Hold before

4–6 h and normal coagulation; check platelets if >4 days of therapy

Restart after

1 h

▲ UFH, intravenous therapeutic

Hold before

4–6 h and normal aPTT / ACT

Restart after

1 h

Low-molecular-weight heparin (LMWH) 2

▲ LMWH, prophylactic dose (e.g. enoxaparin 40 mg/day)

Caveat: CrCl <30: accumulates, extend interval / avoid

Hold before

12 h

Restart after

12 h after block, and ≥4 h after catheter removal

▲ LMWH, therapeutic dose (e.g. enoxaparin 1 mg/kg BID)

Caveat: CrCl <30: markedly prolonged, extend / avoid

Hold before

24 h

Restart after

24 h after block / catheter removal

Vitamin K antagonist 1

▲ Warfarin

Hold before

5 days and INR ≤1.4 (normalised)

Restart after

Resume per surgical plan; remove indwelling catheter only when INR <1.5

Direct oral anticoagulants (DOACs) 4

▲ Rivaroxaban

Caveat: CrCl 30–<50: consider longer; avoid if <30

Hold before

72 h (prophylactic & therapeutic)

Restart after

6 h after needle / catheter

▲ Apixaban

Caveat: Reduce/avoid with significant renal impairment

Hold before

72 h

Restart after

6 h after needle / catheter

▲ Edoxaban

Caveat: Renally cleared, extend if impaired

Hold before

72 h

Restart after

6 h after needle / catheter

▲ Dabigatran

Caveat: Predominantly renal, heavily CrCl-dependent; avoid if <30

Hold before

CrCl ≥80: 72 h · 50–79: 96 h · 30–49: 120 h

Restart after

6 h after needle / catheter

Parenteral thrombin / Xa agents 3

▲ Fondaparinux

Caveat: Renally cleared, avoid in renal impairment

Hold before

Prophylactic dose: 36–42 h (single-pass atraumatic needle); avoid with indwelling catheter

Restart after

6–12 h

▲ Argatroban

Caveat: Hepatically cleared

Hold before

Insufficient data, avoid; ensure normal aPTT

Restart after

—

▲ Bivalirudin

Caveat: Partly renal, prolonged if impaired

Hold before

~10 h and normal aPTT

Restart after

—

Thrombolytics & herbals 2

▲ Thrombolytics (alteplase / tPA, streptokinase)

Hold before

Avoid; ≥48 h and document fibrinogen recovery

Restart after

—

Garlic / Ginkgo / Ginseng

Hold before

No mandated interval, not a contraindication alone

Restart after

No restriction

Key sources

Horlocker et al. ASRA Evidence-Based Guidelines, 4th ed., Reg Anesth Pain Med 2018, asra.com
ESAIC Guideline on neuraxial blockade and antithrombotic agents (2022), esaic.org

Intervals are general adult defaults and are modified by renal/hepatic function, the dose, and whether a catheter is indwelling. This page does not provide drug dosing. Always confirm against the current ASRA/ESAIC text and your institutional protocol before performing a block.