The American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) has published the fifth edition of its guidelines on the use of regional anesthesia in patients receiving direct oral anticoagulants or antiplatelet medications.

The update makes the guidelines consistent with European standards on this topic and adds recommendations for the administration and interpretation of blood tests for some patients (Reg Anesth Pain Med 2025:rapm-2024-105766 ).

One significant change is the replacement of the terms used to refer to dosing. Where the previous guidance described doses of blood thinning medication as either “therapeutic” or “prophylactic,” the new guidelines now use the terms “low dose” and “high dose.” The change creates consistency with European guidelines and provides clearer and more objective guidance on dosing, said first author Sandy Kopp, MD, an anesthesiologist at Mayo Clinic in Rochester, Minn., and the president-elect of ASRA Pain Medicine.

“It’s not helpful to anybody when you have differing guidelines about the same topic,” Kopp said in a virtual press briefing about the update. “One of our co-authors, Dr. Erik Vandermeulen, is also on the European guidelines, so that allows us to speak the same language.

“We also know that, depending on what this medication is used for and what the patient’s comorbidities are, sometimes the same dose can be therapeutic or prophylactic,” Kopp added. “So that’s why we’re now using the terms low and high dose, because that is a little bit more defined.”

Kopp went on to say the update also reflects the wider availability, in the years since the previous edition of the guidelines, of blood tests that can determine whether a patient who has been taking anticoagulants or antiplatelet medications remains anticoagulated after stopping the medication.

“Those have not been easy to access in a lot of institutions, but they’re becoming easier to access,” she said. “And so we put recommendations for what the blood test should show and for which patients you should actually draw the blood test on—not every patient needs a blood test if they follow the recommendations.”

Lisa Leffert, MD, a co-author of the guidelines and the chair of anesthesiology at Yale School of Medicine, in New Haven, Conn., added that the updates include guidance for pregnant women as well as a statement regarding urgent circumstances.

“There’s a lot of planning that goes into using these medications and regional anesthesia, both of which are very important in pregnant women,” said Leffert, who specializes in obstetric anesthesiology. “It has been wonderful to work with the ASRA group to bring it all together for patients and their physicians.”

Raj Gupta, MD, a professor of anesthesiology at Vanderbilt University Medical Center, in Nashville. Tenn., and a member of the ASRA Pain Medicine’s board of directors, who is leading development of the ASRA Coags app—a ground-up refresh of the existing app—said it will make the new guidelines easy to access and apply.

However, Gupta, a member of the Anesthesiology News editorial advisory board, strongly recommended that anesthesiologists take the time to read the paper in its entirety.

“There’s a lot of educational material in there about understanding how these drugs work, what the implications of different testing are, reversal of those medications if you do get in a situation that you don’t expect,” he said. “It is so critical to be able to make a plan with your surgeons and your primary care physicians and your patients, because there’s always going to be a twist or a nuance that you don’t anticipate. The authors of this guideline have done a really good job of bringing a lot of complicated information into one place—it’s a great read for any anesthesiologist.”

By Ajai Srinivas

Gupta, Kopp and Leffert reported no relevant financial disclosures. Titled “Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy,” the updated guidelines will also be available as an app for both iPhone and Android.