{"id":7496,"date":"2026-06-20T04:19:28","date_gmt":"2026-06-20T04:19:28","guid":{"rendered":"https:\/\/gothi.gov.eg\/?page_id=7496"},"modified":"2026-06-20T04:21:32","modified_gmt":"2026-06-20T04:21:32","slug":"%d8%a3%d9%85%d8%b1%d8%a7%d8%b6-%d8%a7%d9%84%d8%b1%d9%88%d9%85%d8%a7%d8%aa%d9%8a%d8%b2%d9%85-%d9%88-%d8%a7%d9%84%d9%85%d9%86%d8%a7%d8%b9%d8%a9-%d8%a7%d9%84%d8%a5%d9%83%d9%84%d9%8a%d9%86%d9%8a%d9%83","status":"publish","type":"page","link":"https:\/\/gothi.gov.eg\/?page_id=7496","title":{"rendered":"\u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0631\u0648\u0645\u0627\u062a\u064a\u0632\u0645 \u0648 \u0627\u0644\u0645\u0646\u0627\u0639\u0629 \u0627\u0644\u0625\u0643\u0644\u064a\u0646\u064a\u0643\u064a\u0629"},"content":{"rendered":"\t\t
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  1. <\/li>\n<\/ol>\n\n\n\n

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    \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0631\u0648\u0645\u0627\u062a\u064a\u0632\u0645 \u0648 \u0627\u0644\u0645\u0646\u0627\u0639\u0629 \u0627\u0644\u0625\u0643\u0644\u064a\u0646\u064a\u0643\u064a\u0629\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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    \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Management of Rheumatoid Arthritis <\/span>\n\n <\/h5>\n\n
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    \u0645\u062a\u0637\u0644\u0628\u0627\u062a \u0627\u0644\u0625\u0643\u0645\u0627\u0644<\/span>\n
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    “last update: 28 Oct \u00a02025”\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0Download Guideline<\/u><\/a>
    <\/strong><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
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    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
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    – Executive Summary<\/h3>\n
    \n

    \u00a0<\/p>\n

    This guideline offers evidence-based recommendations on the diagnosis and management of Rheumatoid Arthritis (RA). The recommendations are intended to provide healthcare professionals with practical guidance on diagnosis and management of Rheumatoid Arthritis, and improving health outcomes for people living with RA.<\/p>\n

    \u27a1\ufe0fClinical Evaluation:<\/strong><\/p>\n

    1.\u00a0\u00a0\u00a0\u00a0<\/strong>It is advised to suspect that the patient is a case of Rheumatoid Arthritis if he has morning stiffness lasting >1 hour, improving with activity, and small-joint arthritis affecting the hands and feet\u00a0(Good Practice Statement).<\/i><\/p>\n

    2.\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>You should diagnose a case of RA if the<\/span><\/strong>\u00a0examination of the extremities reveals the presence of synovitis (<\/span>soft tissue joint swelling<\/span>), which will typically present as a symmetric polyarthritis affecting the metacarpophalangeal (MCP), metatarsophalangeal (MTP), and proximal interphalangeal (PIP) joints\u00a0(Good Practice Statement).<\/i><\/span><\/p>\n

    \u27a1\ufe0f Laboratory Tests:<\/strong><\/p>\n

    3.\u00a0\u00a0\u00a0\u00a0<\/strong>It is advised to do:<\/strong><\/p>\n

    \u00b7\u00a0\u00a0Rheumatoid factor (RF)<\/strong>: Present in 70\u201380% of RA cases (but not specific; seen in other autoimmune diseases and even in healthy elderly persons).<\/p>\n

    \u00b7\u00a0\u00a0Anti-Cyclic Citrullinated Peptide (Anti-CCP) Antibodies<\/strong>: highly specific for RA (90\u201395%), aiding early diagnosis.<\/i><\/p>\n

    \u00b7\u00a0\u00a0Inflammatory markers<\/strong>:\u00a0<\/strong>elevated ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) during activity\u00a0(Good Practice Statement).<\/i><\/p>\n

    \u00a0Imaging Studies:<\/strong><\/p>\n

    4.\u00a0\u00a0<\/strong>Do\u00a0plain radiographs hands & feet\u00a0<\/strong>that might demonstrate periarticular osteopenia, joint space narrowing and bone erosions, and their absence does not rule out RA diagnosis\u00a0<\/strong>(Good Practice Statement).<\/i><\/p>\n

    5.\u00a0\u00a0\u00a0\u00a0<\/strong>Ultrasonography:\u00a0<\/strong>may be of help if done by expert person in selected cases & should not be the only tool to rely on for diagnosis and treatment strategies\u00a0<\/strong>(Good Practice Statement)<\/i>.<\/p>\n

    6.\u00a0\u00a0\u00a0<\/strong>You can use the\u00a0ACR\/EULAR 2010 classification criteria<\/strong>, to aid the diagnosis\u00a0(Good Practice Statement).<\/i><\/p>\n

    \u27a1\ufe0f\u00a0Treatment of rheumatoid arthritis:<\/strong><\/p>\n

    7.\u00a0\u00a0\u00a0\u00a0We recommend starting treatment as soon as the diagnosis of RA is made.\u00a0<\/strong>(SOR: Strong).<\/i><\/p>\n

    8.\u00a0\u00a0\u00a0\u00a0We recommend applying \u201cTreat-to-target strategy\u201d: treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient, according to ACR\/ EULAR provided Boolean- based and index- based remission criteria.\u00a0(SOR: Strong).<\/i><\/p>\n

    9.\u00a0\u00a0\u00a0\u00a0<\/i>We recommend frequent monitoring of the disease activity every 1\u20133 months during active disease and then every 3\u20136 months once remission\/ low disease activity achieved, using a validated measure. We advise the use of\u00a0CDAI<\/strong>\u00a0(Clinical Disease Activity Index) as a tool to measure the activity state (Refer to annexes). Remission \u2264 2.8, low disease activity >2.8-10, moderate disease activity >10-22, high disease activity >22-76.\u00a0(SOR: Strong).<\/i><\/i><\/p>\n

    10.\u00a0\u00a0\u00a0\u00a0\u00a0<\/i>Therapy should be adjusted if there is no improvement by 50% from the baseline measures by 3 months after the start of treatment or the target has not been reached by 6 months\u00a0(SOR: Strong).<\/i><\/i><\/p>\n

    11.\u00a0\u00a0MTX should be part of the first treatment strategy.\u00a0(SOR: Strong).<\/i><\/p>\n

    12.\u00a0We strongly recommend starting the first line of treatment strategy with conventional disease-modifying antirheumatic drug (csDMARD) monotherapy using methotrexate (15\u201325 mg\/week) s.c. or i.m. injections or oral tablets. Folic acid supplementation 5-10 mg \/week should be given 24hrs after MTX administration (in a single or divided doses), not to be taken the day of MTX.\u00a0(SOR: Strong).<\/i><\/p>\n

    13.\u00a0We suggest implementing strategies to improve MTX tolerability in patients experiencing side effects, before switching to another DMARD. These include increasing folic acid dose, splitting oral MTX dose over 24 h, or switching between oral and parenteral routes of MTX administration.\u00a0(SOR: Conditional).<\/i><\/p>\n

    14.\u00a0\u00a0<\/i>We advise treatment with Leflunomide (20 mg\/day) or sulfasalazine (3 g\/day), when MTX is not tolerated or contraindicated. Consider hydroxychloroquine (200\u2013400 mg) for mild or palindromic disease without poor prognostic factors.\u00a0<\/strong>(SOR: Conditional).<\/i><\/i><\/p>\n

    15.\u00a0\u00a0We suggest adding other csDMARD to MTX or using a different combination csDMARD therapy, if no significant improvement at least 50% from the baseline measures has been achieved by 3 months (DMARD combination therapy means double or triple csDMARDs therapy).\u00a0(SOR: Conditional).<\/i><\/p>\n

    16.\u00a0\u00a0<\/i>You should consider short-term glucocorticoids when initiating or changing csDMARDs\u00a0(<\/strong>as a bridge therapy)<\/strong>; the dose and route of administration may vary, orally at doses up to 5-10 mg\/day, or a single intramuscular injection of 120 mg methylprednisolone. Oral steroid therapy should be tapered as rapidly as clinically feasible, within 3-6 months from treatment start\u00a0provided that the patient doesn’t flare.\u00a0<\/strong>After 6 months, if the patient is still active & doesn’t have access to bDMARDs or tsDMARDs, longer term steroids can be used up to 5 mg per day.\u00a0(SOR: Strong).<\/i><\/i><\/p>\n

    17.\u00a0\u00a0We advise starting bDMARDs or tsDMARDs after failure of 2 or more csDMARDs<\/strong>\u00a0(when there is no significant improvement by at least 50% from the baseline measures by 3 months or treatment target is not achieved within 6 months).\u00a0(SOR: Conditional).<\/i><\/p>\n

    18.\u00a0\u00a0The choice of a bDMARD (bio-originator or biosimilar) depends on the availability of the drug, drug cost, associated co-morbidities and patient preference.\u00a0(SOR: Strong).<\/i><\/p>\n

    19.\u00a0\u00a0When tsDMARDs (JAKi) are considered, risk factors must be taken into account:<\/p>\n

    \u00b7\u00a0 \u00a0Age > 65 years.<\/p>\n

    \u00b7\u00a0 \u00a0History of current or past smoking.<\/p>\n

    \u00b7\u00a0\u00a0Cardiovascular risk factors: such as diabetes, obesity, and hypertension.<\/p>\n

    \u00b7\u00a0 \u00a0Risk factors for malignancy.<\/p>\n

    \u00b7\u00a0Current or previous history of malignancy.<\/p>\n

    \u00b7\u00a0\u00a0Risk factors for thromboembolic events: e.g. history of myocardial infarction or heart failure, cancer, inherited blood clotting disorders or a history of blood clots, hormonal contraceptives or hormone replacement therapy, undergoing major surgery or prolonged immobility.\u00a0(SOR: Strong).<\/i><\/p>\n

    20.\u00a0 If a bDMARD or tsDMARD has failed, treatment with another bDMARD or tsDMARD should be considered. Before switching, reassess\u00a0adherence, comorbidities, diagnosis, and objective inflammation<\/strong>.\u00a0<\/strong>Distinguish between:<\/p>\n

    \u00b7\u00a0\u00a0Primary treatment failure:<\/strong>
    \u2013No clinically relevant \u00a0improvement ( at least 50% from baseline measures) or treatment target is not achieved within 6 months of adequate therapy.
    \u2013 \u2192In this case, switch to a drug with a\u00a0different mechanism of action<\/strong>\u00a0(e.g., from a TNFi to a non-TNFi\u00a0 such as an IL-6 receptor inhibitor, rituximab, or a JAK inhibitor).<\/p>\n

    \u00b7\u00a0\u00a0Secondary treatment failure:<\/strong>
    \u2013 Loss of efficacy after an initial adequate response.
    \u2013 Suggests\u00a0immunogenic or pharmacokinetic failure<\/strong>\u00a0\u2192\u00a0switching within the same class can be considered<\/strong>\u00a0(e.g. from one TNFi to another), especially if immunogenicity or anti-drug antibodies are suspected.
    \u2013 If the response is not regained, switch to a drug with a\u00a0different mechanism of action<\/strong>.<\/p>\n

    \u00a0Patients who fail\u00a0multiple b\/tsDMARDs<\/strong>\u00a0despite adequate therapy should be classified as having\u00a0difficult-to-treat RA<\/strong>, in line with EULAR criteria\u00a0(SOR: Strong).<\/i><\/p>\n

    21.\u00a0 bDMARDs and tsDMARDs could be combined with a csDMARD usually MTX;<\/strong>\u00a0in patients who cannot use csDMARDs as comedication, IL- 6i and tsDMARDs may have some advantages compared with other bDMARDs.\u00a0(SOR: Strong).<\/i><\/p>\n

    22.\u00a0You should give a trial of tapering the bDMARDs or tsDMARDs after GCs have been discontinued, if the patient has sustained disease remission (i.e. remission for \u2265 6 consecutive months) either by decreasing the dose or increasing the time intervals whenever applicable according to the drug used with continuation of other csDMARDs.\u00a0(SOR: Strong).<\/i><\/p>\n

    Recommendations in RA patients with comorbidities:\u00a0<\/strong><\/u><\/p>\n

    23.\u00a0 \u00a0In patients who develop double-fold elevation of liver enzymes, reduce MTX & LEF to half dose. If reaches threefold or more, stop MTX and LEF, if persistent over 6 months re-evaluate the virology.\u00a0(SOR: Strong).<\/i><\/p>\n

    24.\u00a0\u00a0\u00a0\u00a0\u00a0In patients with non-alcoholic fatty liver disease (NAFLD), Methotrexate is conditionally recommended over alternative DMARDs for DMARD-naive patients with NAFLD, normal liver enzymes and liver function tests, and no evidence of advanced liver fibrosis who have moderate-to-high disease activity.\u00a0\u00a0(SOR: Conditional).<\/i><\/p>\n

    25.\u00a0\u00a0\u00a0\u00a0\u00a0Patients with hepatitis B viral infection should receive antiviral treatment before starting bDMARDs with close monitoring as well as follow up with the hepatologists after starting biological therapy. (SOR: Strong).<\/i><\/p>\n

    26.\u00a0\u00a0\u00a0\u00a0\u00a0<\/i>In hypertensive patients, be careful regarding salt and water retention property of Leflunomide. Baseline measurement of blood pressure is recommended with adjustment of blood pressure therapy if required.\u00a0\u00a0(SOR: Conditional).<\/i><\/i><\/p>\n

    27.\u00a0\u00a0\u00a0\u00a0\u00a0In patients with New York Heart Association class 3 or 4 heart failure, non-TNFi bDMARD are recommended.\u00a0(SOR: Strong).<\/i><\/p>\n

    28.\u00a0\u00a0\u00a0\u00a0\u00a0Patients complicated with interstitial lung disease: Interleukin-6 inhibitor (IL-6i) or Rituximab could be considered.\u00a0(SOR: Conditional).<\/i><\/p>\n

    29.\u00a0\u00a0\u00a0\u00a0\u00a0<\/i>In patients with history of lymphoproliferative disorder, rituximab is preferable over other bDMARDs\u00a0(SOR: Conditional).<\/i><\/i><\/p>\n

    30.\u00a0\u00a0\u00a0\u00a0\u00a0MTX, Leflunomide, Rituximab, Tocilizumab and JAKi are contraindicated in pregnancy & lactation.\u00a0(SOR: Strong).<\/i><\/p>\n

    31.\u00a0\u00a0\u00a0\u00a0\u00a0All TNFi, hydroxychloroquine, corticosteroids, and sulfasalazine can be used during pregnancy and lactation.\u00a0(SOR: Conditional).<\/i><\/p>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n

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    \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic therapy <\/span>\n\n <\/h5>\n\n
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    \u00a0 \u00a0\u00a0Download Guideline<\/strong><\/u><\/a><\/strong><\/span><\/h4>\n



    – Executive Summary<\/h3>\n
    \n

    \u00a0<\/p>\n

    These Guidelines deal with the cornerstone recommendations of\u00a0<\/i><\/b>Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy.<\/i><\/b><\/i><\/b><\/p>\n

    1.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Administration of thromboprophylaxis<\/u><\/b><\/p>\n

    1.1\u00a0<\/b>For each of the antithrombotic agents, we suggest that clinicians follow the FDA-approved dosing guidelines\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Direct Oral Anticoagulants (DOAC)<\/u><\/b><\/p>\n

    2.1\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving a High\u00a0<\/u>dose of Apixaban (Eliquis)<\/b><\/p>\n

    2.1.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a high dose of apixaban be discontinued at least 72 hours prior to neuraxial block or deep plexus\/peripheral block. Consider checking apixaban or aXa plasma level if <72 hours\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.1.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a residual apixaban plasma level <30\u2009ng\/mL or a residual aXa activity plasma level \u22640.1\u2009IU\/mL is acceptable prior to neuraxial block or deep plexus\/peripheral block\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.1.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that needle placement\/catheter removal occurs at least 24 hours prior to the first postoperative dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.2\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving a Low dose of Apixaban (Eliquis)<\/b><\/p>\n

    2.2.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a low dose of apixaban be discontinued for at least 36 hours prior to neuraxial block or deep plexus\/peripheral block. Consider checking apixaban or aXa plasma level if <36 hours\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.2.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a residual apixaban plasma level <30\u2009ng\/mL or a residual aXa activity plasma level \u22640.1\u2009IU\/mL is acceptable prior to neuraxial block or deep plexus\/peripheral block\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.2.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that needle placement\/catheter removal occurs at least 6 hours prior to the first postoperative dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.3\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving a high dose of edoxaban (Savaysa)<\/b><\/p>\n

    2.3.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a high dose of edoxaban be discontinued for at least 72 hours prior to neuraxial block or deep plexus\/peripheral block. Consider checking edoxaban or aXa activity plasma level if <72 hours\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.3.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a residual edoxaban plasma level <30\u2009ng\/mL or a residual aXa activity plasma level \u22640.1\u2009IU\/mL is acceptable prior to neuraxial block or deep plexus\/peripheral block\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.3.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that needle placement\/catheter removal occurs at least 24 hours prior to the first (postoperative) dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.4\u00a0\u00a0\u00a0<\/b>Management of the patient receiving a Low dose of Edoxaban (Savaysa)<\/b><\/b><\/p>\n

    \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 There is no FDA-approved medical indication for low-dose edoxaban.<\/b><\/p>\n

    2.5\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving High dose of Rivaroxaban (Xarelto)<\/b><\/p>\n

    2.5.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a high dose of rivaroxaban be discontinued for at least 72 hours prior to neuraxial block or deep plexus\/peripheral block. Consider checking rivaroxaban or aXa activity plasma level if <72 hours\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.5.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a residual rivaroxaban plasma level <30\u2009ng\/mL or a residual aXa activity plasma level \u22640.1\u2009IU\/mL is acceptable prior to neuraxial block or deep plexus\/peripheral block\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.5.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that needle placement\/catheter removal occurs at least 24 hours prior to the first postoperative dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.6\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving a Low dose of Rivaroxaban (Xarelto)<\/b><\/p>\n

    2.6.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a low dose of rivaroxaban be discontinued for at least 24 hours (30 hours if CrCl <30\u2009mL\/min) prior to neuraxial block or deep plexus\/peripheral block. Consider checking rivaroxaban or aXa activity plasma level if <24 hours\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.6.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a residual rivaroxaban plasma level <30\u2009ng\/mL or a residual aXa activity plasma level \u22640.1\u2009IU\/mL<\/b>\u00a01<\/sup><\/b><\/a>\u00a0is acceptable prior to neuraxial block or deep plexus\/peripheral block\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.6.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that needle placement\/catheter removal occurs at least 6 hours prior to the first postoperative dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.7\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving a High dose of Dabigatran (Pradaxa)<\/b><\/p>\n

    2.7.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a high dose of dabigatran be discontinued for at least 72 hours in patients with a CrCl \u226550\u2009mL\/min prior to neuraxial block or deep plexus\/peripheral block. Consider checking dabigatran plasma level if <72 hours\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.7.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a high dose of dabigatran be discontinued for 120 hours in patients with a CrCl 30\u201349\u2009mL\/min prior to neuraxial block or deep plexus\/peripheral block. Consider checking dabigatran plasma level if <120 hours\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.7.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest against the performance of neuraxial or deep plexus\/peripheral blocks in patients with a CrCl <30\u2009mL\/min unless a dabigatran plasma level is obtained and <30\u2009ng\/mL\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.7.4\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Prior to neuraxial block or deep plexus\/peripheral block we suggest that a residual dabigatran plasma level <30 ng\/mL is acceptable\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.7.5\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that needle placement\/catheter removal occurs at least 24 hours prior to the first postoperative dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    2.8\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving a Low dose of Dabigatran (Pradaxa)<\/b><\/p>\n

    2.8.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a low dose of dabigatran be discontinued for at least 48 hours prior to neuraxial block or deep plexus\/peripheral block. Consider checking dabigatran plasma level if <48 hours\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.8.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that a residual dabigatran plasma level <30 ng\/mL is acceptable prior to neuraxial block or deep plexus\/peripheral block\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.8.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest against the performance of neuraxial or deep plexus\/peripheral blocks in patients with a CrCl <30\u2009mL\/min unless a dabigatran plasma level is obtained and <30\u2009ng\/mL\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    2.8.4\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that needle placement\/catheter removal occurs at least 6 hours prior to the first postoperative dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    3.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Use of Direct oral anticoagulant (DOAC) antidotes to facilitate placement of neuraxial block or deep plexus\/peripheral block<\/u><\/b><\/p>\n

    3.1\u00a0\u00a0\u00a0<\/b>Suggest<\/b>\u00a0against<\/i><\/b>\u00a0<\/i>the use of idarucizumab, andexanet alfa,\u00a0<\/b>prothrombin complex concentrates<\/b>\u00a0(PCC), or\u00a0<\/b>activated prothrombin complex concentrates (<\/b>aPCC) to reverse DOAC anticoagulant activity to enable the safe performance of a neuraxial intervention in routine patients\u00a0<\/b>(<\/b>Conditional<\/b>)<\/b><\/p>\n

    4.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Intravenous and Subcutaneous Unfractionated Heparin<\/u><\/b><\/p>\n

    Management of neuraxial block or deep plexus\/peripheral block in the patient receiving Unfractionated Heparin<\/b><\/p>\n

    4.1\u00a0\u00a0\u00a0<\/b>We recommend daily review of the patient\u2019s medical record to determine the concurrent use of medications that affect other pathways of hemostasis. These medications include antiplatelet medications, LMWH, and oral anticoagulants\u00a0<\/b>(Strong)<\/b><\/u><\/b><\/p>\n

    4.2\u00a0\u00a0\u00a0<\/b>Since heparin-induced\u00a0<\/b>thrombocytopenia\u00a0<\/b>may occur during heparin administration, we recommend that patients receiving intravenous or subcutaneous UFH for >4\u2009days have a platelet count assessed\u00a0<\/b>(Strong)<\/b><\/p>\n

    4.3\u00a0\u00a0\u00a0<\/b>Intravenous heparin<\/b><\/p>\n

    4.3.1\u00a0 \u00a0 \u00a0 \u00a0<\/b>Discontinue Intravenous heparin infusion for a minimum of 4\u20136\u2009hours and coagulation status be assessed and normal prior to neuraxial block or deep plexus\/peripheral block\u00a0<\/b>(Strong)<\/b><\/p>\n

    4.3.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Delay intravenous heparin administration for a minimum of 1 hour after needle placement\u00a0<\/b>(Strong)<\/b><\/p>\n

    4.3.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>It is not recommended to maintain neuraxial or deep plexus catheters in the setting of continuous intravenous heparin administration. In the event of unanticipated heparinization, we recommend monitoring the patient with an indwelling catheter to allow for early detection of motor deficits and consider use of minimal concentration of local anesthetics to enhance early detection of a neuraxial hematoma\u00a0<\/b>(Strong)<\/b><\/p>\n

    4.3.4\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Although the occurrence of a bloody or difficult neuraxial needle placement may increase the risk of hematoma, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case is recommended\u00a0<\/b>(Strong)<\/b><\/p>\n

    \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Heparinization during cardiopulmonary bypass<\/b><\/p>\n

    4.3.5\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>It is not recommended to maintain neuraxial or deep plexus\/peripheral catheters in the setting of full anticoagulation during\u00a0<\/b>cardiac surgery.\u00a0<\/b>If unanticipated heparinization occurs, we suggest postoperative monitoring of neurological status and consider use of minimal concentration of local anesthetics to enhance early detection of neuraxial hematoma\u00a0<\/b>(Conditional)<\/b><\/p>\n

    4.4\u00a0\u00a0\u00a0<\/b>\u00a0Subcutaneous heparin<\/u><\/b><\/p>\n

    4.4.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Preoperative low-dose UFH\u00a0<\/b>for thromboprophylaxis (<\/b>5000 U two times per day or three times per day). We suggest needle placement occur a minimum of\u00a0<\/b>4\u20136\u2009hours\u00a0<\/b>after heparin administration or coagulation status be assessed and normal\u00a0<\/b>(Conditional)<\/b><\/u><\/b><\/p>\n

    4.4.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Preoperative high dose UFH<\/u><\/b><\/p>\n

    7500\u201310 000 U two times per day or a daily dose of \u226420 000 U<\/b><\/p>\n

    We suggest neuraxial block occur a minimum of\u00a0<\/b>12 hours\u00a0<\/b>after subcutaneous heparin administration and confirmation of normal coagulation status\u00a0<\/b>(Conditional)<\/b><\/p>\n

    >10 000 U subcutaneously per dose, or >20 000 U total daily dose<\/b><\/p>\n

    We suggest neuraxial block occur a minimum of\u00a0<\/b>24 hours after subcutaneous heparin\u00a0<\/b>administration and confirmation of normal coagulation status\u00a0<\/b>(Conditional)<\/b><\/p>\n

    4.4.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Postoperative low-dose UFH<\/u><\/b><\/p>\n

    There is no contraindication to maintaining neuraxial catheters in the\u00a0<\/b>presence of low-dose UFH.<\/b>\u00a0We suggest catheter removal occurs a minimum of\u00a0<\/b>4\u20136\u2009hours\u00a0<\/b>after heparin administration. Subsequent heparin administration may occur immediately after catheter removal\u00a0<\/b>(Conditional)<\/b><\/p>\n

    4.4.4\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Postoperative high-dose UFH<\/u><\/b><\/p>\n

    The safety of indwelling neuraxial catheters in patients receiving doses >5000 U at a time or >15\u2009000 U of UFH daily has not been established. We suggest that the risk and benefits be assessed on an individual basis and that techniques to facilitate detection of new\/progressive neurological deficits (eg, enhanced neurological monitoring occur and neuraxial solutions to minimize sensory and motor block) be applied\u00a0<\/b>(Conditional)<\/b><\/p>\n

    5.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Low molecular weight heparin (LMWH)<\/u><\/b><\/p>\n

    5.1\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving low molecular weight heparin<\/u><\/b><\/p>\n

    5.1.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>The aXa level is Not predictive of the risk of bleeding, although it may be useful in monitoring efficacy of therapy with high-dose regimens. We recommend against the<\/b>\u00a0routine<\/i><\/b>\u00a0<\/i>use of aXa level monitoring\u00a0<\/b>(Strong)<\/b><\/u><\/b><\/p>\n

    5.1.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Heparin-induced thrombocytopenia may occur during LMWH administration; therefore, we recommend that patients receiving LMWH for >4\u2009days have a platelet count assessed prior to needle placement\u00a0<\/b>(Strong)<\/b><\/u><\/b><\/p>\n

    5.1.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>The presence of blood during needle and catheter placement does not necessitate postponement of surgery. We suggest that initiation of LMWH therapy in this setting should be delayed for 24 hours postoperatively and that this consideration be discussed with the surgeon\u00a0<\/b>(Strong)<\/b><\/p>\n

    5.2\u00a0\u00a0\u00a0<\/b>Preoperative LMWH<\/b><\/p>\n

    5.2.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>In patients receiving low-dose LMWH, we recommend delay of at least 12 hours prior to needle\/catheter placement\u00a0<\/b>(Stong)<\/b><\/b><\/p>\n

    5.2.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>In patients receiving high (therapeutic) doses of LMWH, we recommend delay of at least 24 hours prior to needle\/catheter placement\u00a0<\/b>(Stong)<\/b><\/p>\n

    5.3\u00a0\u00a0\u00a0<\/b>Postoperative LMWH<\/b><\/p>\n

    5.3.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We recommend against concomitant administration of medications affecting hemostasis, such as antiplatelet drugs, standard heparin, or dextran, regardless of LMWH dosing regimen when there is an indwelling neuraxial catheter\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    5.3.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Twice-daily low dose. We recommend the first dose of LMWH be administered the following day and at least 12 hours after needle\/catheter placement. Indwelling catheters should be removed<\/b>\u00a0prior<\/i><\/b>\u00a0<\/i>to initiation of LMWH. Administration of LMWH should be delayed for 4 hours after catheter removal\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    5.3.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Single daily low dose. We recommend the first postoperative LMWH dose should be administered at least 12 hours after needle\/catheter placement. Indwelling neuraxial catheters do not appear to represent increased risk and may be maintained. The catheter should be removed 12 hours after the last dose of LMWH. Subsequent LMWH dosing should occur at least 4 hours after catheter removal\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    5.3.4\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Single or twice-daily high (<\/b>\u00a0therapeutic<\/i><\/b>\u00a0<\/i>) dosing. High-dose LMWH may be resumed 24 hours after non-high-bleeding-risk surgery and 48\u201372\u2009hours after high-bleeding-risk surgery. We recommend that indwelling neuraxial catheters be removed 4\u2009hours<\/b>\u00a0prior<\/i><\/b>\u00a0<\/i>to the first postoperative dose and the first postoperative dose should be at least 24 hours after needle\/catheter placement, whichever is greater\u00a0<\/b>(Strong)<\/b><\/p>\n

    6.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Antiplatelet Medications<\/u><\/b><\/p>\n

    Management of neuraxial block or deep plexus\/peripheral block in the patient taking NSAIDs<\/b><\/p>\n

    6.1\u00a0\u00a0\u00a0<\/b>NSAIDs appear to represent no added risk for the development of major bleeding after regional anesthetic techniques. NSAIDs (including aspirin) do not create a level of risk that will interfere with the performance of neuraxial or deep plexus\/peripheral blocks. In patients receiving these medications, we do not identify specific concerns as to the timing of single-injection or catheter techniques, postoperative monitoring, or the timing of neuraxial catheter removal.\u00a0<\/b>(Strong)<\/b><\/p>\n

    6.2\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient taking Thienopyridines (Clopidogrel, Prasugrel)<\/b><\/p>\n

    6.2.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Based on labeling and surgical\/procedural experience, the suggested time interval between discontinuation of thienopyridine therapy and needle placement is 5\u20137\u2009days for clopidogrel, and 7\u201310\u2009days for prasugrel\u00a0<\/b>(<\/b>Conditional<\/b>)<\/b><\/p>\n

    6.2.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Neuraxial and deep plexus\/peripheral catheters should not be maintained with prasugrel due to the rapid onset. However, since the antiplatelet effect is not immediate with clopidogrel, they may be maintained for 1\u20132\u2009days, provided a loading dose of the antiplatelet agent is not administered\u00a0<\/b>(<\/b>Conditional<\/b>)<\/b><\/p>\n

    6.2.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Thienopyridine therapy may be resumed immediately after needle placement\/catheter removal, provided a loading dose of the drugs is not administered. If a loading dose is administered, we suggest a time interval of 6 hours between catheter removal and administration\u00a0<\/b>(<\/b>Conditional<\/b>)<\/b><\/p>\n

    6.3\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient taking Ticagrelor<\/b><\/p>\n

    6.3.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Based on labeling and surgical\/procedural experience, the recommended time interval between discontinuation of ticagrelor therapy and needle placement is 5 days\u00a0<\/b>(<\/b>Conditional<\/b>)<\/b><\/b><\/p>\n

    6.3.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Neuraxial catheters should not be maintained with ticagrelor due to the rapid onset\u00a0<\/b>(<\/b>Conditional<\/b>)<\/b><\/b><\/p>\n

    6.3.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Ticagrelor therapy may be resumed immediately after needle placement\/catheter removal, provided a loading dose of the drug is not administered. If a loading dose is administered, we suggest a time interval of 6 hours between catheter removal and administration\u00a0<\/b>(<\/b>Conditional<\/b>)<\/b><\/p>\n

    6.4\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient taking platelet GP IIb\/IIa inhibitors<\/b><\/p>\n

    6.4.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>The platelet GP IIb\/IIIa inhibitors exert a profound effect on platelet aggregation. Following administration, the time to normal platelet aggregation is 24\u201348\u2009hours for abciximab and 4\u20138\u2009hours for eptifibatide and tirofiban. We recommend that needle placement should be avoided until platelet function\u2014as impacted by the GP IIb\/IIIa inhibitor\u2014has recovered. Caution in patients on dual therapy who may still have residual NSAID effect\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    6.4.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Postoperative. Although GP IIb\/IIIa antagonists are contraindicated within 4\u2009weeks of surgery, should one be emergently administered in the postoperative period following a neuraxial or deep plexus\/peripheral technique, we recommend the neuraxial infusion should be limited to drugs minimizing sensory and motor block to facilitate assessment of neurological function and that the patient be carefully monitored neurologically\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    6.4.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Timing of catheter removal is based on ongoing risk of thromboembolism and need for continued antithrombotic therapy and the potential for spinal bleeding during catheter maintenance and removal\u00a0<\/b>(Conditional)<\/b><\/p>\n

    6.5\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient taking Cilostazol<\/b><\/p>\n

    6.5.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>The risk of serious bleeding in the presence of residual cilostazol effect is unknown. Based on the elimination half-life, we suggest that needle placement be avoided for 2\u2009days after discontinuation of cilostazol\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    6.5.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that neuraxial and deep plexus\/peripheral catheters be removed prior to reinstitution of cilostazol therapy postoperatively\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    6.5.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that the first postoperative dose of cilostazol be administered 6 hours after neuraxial or deep plexus\/peripheral catheter removal\u00a0<\/b>(Conditional)<\/b><\/p>\n

    6.6\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient taking Cangrelor<\/b><\/p>\n

    6.6.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>The risk of serious bleeding in the presence of residual cangrelor effect is unknown. Based on the elimination half-life, we suggest that needle placement be avoided for 3\u2009hours after discontinuation of cangrelor\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    6.6.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that neuraxial and deep plexus\/peripheral catheters be removed prior to reinstitution of cangrelor therapy postoperatively\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    6.6.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that the first postoperative dose of cangrelor be administered 8 hours after neuraxial or deep plexus\/peripheral catheter removal\u00a0<\/b>(Conditional)<\/b><\/p>\n

    7.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Parenteral Direct Thrombin Inhibitors<\/u><\/b><\/p>\n

    Management of neuraxial block or deep plexus\/peripheral block in the patient taking parenteral Thrombin inhibitors (Argatroban, Bivalirudin, and Desirudin)<\/b><\/p>\n

    7.1\u00a0\u00a0\u00a0<\/b>In patients receiving parenteral thrombin inhibitors, we suggest against the performance of neuraxial techniques\u00a0<\/b>(Conditional)<\/b><\/p>\n

    \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Parenteral anti-Xa agents<\/b><\/p>\n

    7.2\u00a0\u00a0\u00a0<\/b>Management of neuraxial block or deep plexus\/peripheral block in the patient receiving Fondaparinux<\/b><\/p>\n

    \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Low-dose fondaparinux (2.5 mg once per day)<\/i><\/b><\/p>\n

    7.2.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest holding low-dose fondaparinux (2.5 mg once per day) for 36 hours (young patients) to 42 hours (elderly patients) in healthy patients with normal renal function\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    7.2.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest holding fondaparinux for a minimum of 58 hours in patients with moderate renal insufficiency (CrCl 30\u201350 mL\/min)\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    7.2.3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest not performing neuraxial or deep plexus\/peripheral blocks in patients with severe renal impairment (CrCl <30\u2009mL\/min) due to the 72\u2009hours half-life\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    7.2.4\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest testing aXa activity calibrated to fondaparinux if placing the needle prior to these recommended times is considered (aXa \u22640.1 IU\/mL)\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/i><\/b><\/i><\/b><\/p>\n

    \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0High-dose fondaparinux (5\u201310 mg once per day)<\/i><\/b><\/p>\n

    7.2.5\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest holding high-dose fondaparinux (5-10 mg once per day) for a minimum of 70 hours (in young patients) and for a minimum of 105 hours (in elderly patients) with normal renal function\u00a0<\/b>(Conditional)<\/b><\/p>\n

    7.2.6\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest testing aXa activity calibrated to fondaparinux if placing needle prior to the recommended times is considered (aXa \u22640.1 IU\/mL)\u00a0<\/b>(Conditional)<\/b><\/p>\n

    7.2.7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>We suggest that neuraxial catheters be removed at least 6 hours<\/b>\u00a0prior<\/i><\/b>\u00a0<\/i>to the first postoperative dose\u00a0<\/b>(Conditional)<\/b><\/p>\n

    8.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Fibrinolytic and Thrombolytic drugs<\/u><\/b><\/p>\n

    Management of neuraxial block or deep plexus\/peripheral block in the patient receiving Thrombolytic therapy<\/b><\/p>\n

    8.1\u00a0\u00a0\u00a0<\/b>In patients scheduled to receive thrombolytic therapy, we recommend that the patient be queried, and the medical record reviewed for a recent history of lumbar puncture, spinal or epidural anesthesia, or epidural steroid injection to allow appropriate monitoring. Guidelines detailing original contraindications for thrombolytic drugs suggest avoidance of these drugs for 10 days following puncture of non-compressible vessels\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    8.2\u00a0\u00a0\u00a0<\/b>In patients who have received fibrinolytic and thrombolytic drugs, we recommend against needle placement for at least 48 hours. Documentation of normalization of clotting studies (including fibrinogen) is suggested\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    8.3\u00a0\u00a0\u00a0<\/b>In those patients who have received neuraxial blocks at or near the time of fibrinolytic and thrombolytic therapy, we recommend that frequent neurological monitoring (eg, every 2 hours) should be continued for at least 48 hours after the last dose. If neuraxial blocks have been combined with fibrinolytic and thrombolytic therapy and ongoing epidural catheter infusion, we recommend the infusion should be limited to drugs minimizing sensory and motor block to facilitate assessment of neurological function\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    \u00a0<\/u><\/b><\/p>\n

    9.\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Vitamin K antagonists (warfarin)<\/u><\/b><\/p>\n

    \u00a0<\/u><\/b><\/p>\n

    Management of neuraxial block or deep plexus\/peripheral block in the patient on Warfarin<\/b><\/p>\n

    \u00a0<\/b><\/p>\n

    9.1\u00a0\u00a0\u00a0<\/b>We recommend that the anticoagulant therapy be stopped 5 days prior to the planned procedure, and the INR be measured and normalized (normal range of the local laboratory) prior to needle placement.\u00a0<\/b>(Strong)<\/b><\/p>\n

    9.2\u00a0\u00a0\u00a0<\/b>In patients receiving an initial dose of warfarin prior to surgery, we suggest the INR should be checked prior to needle placement if the first dose was given >24 hours earlier, or if a second dose of oral anticoagulant has been administered\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    9.3\u00a0\u00a0\u00a0<\/b>In patients receiving low-dose warfarin therapy during epidural analgesia, we suggest that their INR be monitored daily\u00a0<\/b>(Conditional)<\/b><\/b><\/p>\n

    9.4\u00a0\u00a0\u00a0<\/b>We suggest that neuraxial catheters be removed when the INR is <1.5<\/b>\u00a0(Conditional)<\/b><\/b><\/p>\n

    9.5\u00a0\u00a0\u00a0<\/b>In patients with INR >1.5 but <3, the increased risk of maintaining a neuraxial catheter remains unknown. We suggest indwelling catheters may be maintained or removed with caution, closely following the INR and duration of warfarin therapy.<\/b>\u00a0(Conditional)<\/b><\/b><\/p>\n

    9.6\u00a0\u00a0\u00a0<\/b>In patients with an INR >3, we recommend that the warfarin dose be held or reduced in patients with indwelling neuraxial catheters\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    9.7\u00a0\u00a0\u00a0<\/b>Neurological testing of sensory and motor function should be performed routinely during epidural analgesia for patients on warfarin therapy. To facilitate neurological evaluation, we recommend that the type of analgesic solution be tailored to minimize the degree of sensory and motor blockade\u00a0<\/b>(Strong)<\/b><\/b><\/p>\n

    9.8\u00a0\u00a0\u00a0<\/b>We suggest that neurological assessment be continued for at least 48 hours following catheter removal\u00a0<\/b>(Conditional)<\/b><\/p>\n

    10.\u00a0\u00a0<\/b>Herbal medications<\/u><\/b><\/p>\n

    Management of neuraxial block or deep plexus\/peripheral block in patients using Herbal therapy<\/b><\/p>\n

    10.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>The use of herbal medications does not create a level of risk that will interfere with the performance of neuraxial blocks. We recommend against the mandatory discontinuation of these medications or avoidance of regional anesthetic techniques in patients on these medications\u00a0<\/b>(Strong)<\/b><\/p>\n

    11.\u00a0\u00a0<\/b>Management of neuraxial block in the anticoagulated parturient<\/u><\/b><\/p>\n

    11.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Given the limited pharmacological data on antithrombotic agents in pregnancy and in the absence of a large series of neuraxial techniques in the pregnant population receiving prophylaxis or treatment for venous thromboembolism, we suggest that the recommendations included in this document be applied to parturients\u00a0<\/b>(Conditional)<\/b><\/p>\n

    11.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>However, in circumstances involving select high-risk parturients receiving VTE prophylaxis, and requiring urgent interventions for maternal or fetal indications, the risk of general anesthesia may be greater than neuraxial anesthesia, and exceptions\/modifications of these recommendations may be appropriate\u00a0<\/b>(Conditional)<\/b><\/p>\n

    12.\u00a0\u00a0<\/b>Antithrombotic therapy in pregnancy<\/u><\/b><\/p>\n

    Management of deep plexus\/peripheral block in the anticoagulated patient<\/b><\/p>\n

    12.1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>For patients undergoing deep plexus or deep peripheral block, we recommend that guidelines for neuraxial block be similarly applied\u00a0<\/b>(Strong)<\/b><\/p>\n

    12.2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>For patients undergoing other plexus or peripheral techniques, we suggest performance, catheter maintenance, and catheter removal be based on site compressibility, vascularity, and consequences of bleeding, should it occur\u00a0<\/b>(Conditional)<\/b><\/p>\n<\/b><\/div> <\/div>\n\n <\/div>\n <\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"

    \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0631\u0648\u0645\u0627\u062a\u064a\u0632\u0645 \u0648 \u0627\u0644\u0645\u0646\u0627\u0639\u0629 \u0627\u0644\u0625\u0643\u0644\u064a\u0646\u064a\u0643\u064a\u0629 Management of Rheumatoid Arthritis \u0645\u062a\u0637\u0644\u0628\u0627\u062a \u0627\u0644\u0625\u0643\u0645\u0627\u0644 \u00a0 “last update: 28 Oct \u00a02025”\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7496","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7496","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=7496"}],"version-history":[{"count":5,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7496\/revisions"}],"predecessor-version":[{"id":7504,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7496\/revisions\/7504"}],"wp:attachment":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=7496"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}