Saint Francis Health System Department of Radiology MYELOGRAPHY: to be evaluated prior to myelography.

ANTICOAGULATION Myelography practice guidelines require discontinuation of prior to the procedure in order to avoid serious adverse events from lumbar puncture in the presence of risk. Ideally, the decision to discontinue anticoagulants should be made after discussion with that ’s prescriber. Bridging with intravenous or delaying myelogram until it is safer to perform should be considered if the risks of discontinuing the anticoagulation exceed the benefits of myelography. 1-3

ANTICOAGULATION: recommended hold times pre- and post-myelography Medication Pre-Procedure Post-Procedure (Reopro) 48 hours 2 hours± (Activase, t-PA) full dose 10 days 10 days alteplase (Cathflo Activase) 2mg dose No restrictions No restrictions (Eliquis) 3 days* 6 hours aPTT < 40 seconds 2 hours± aspirin (Ecotrin) No restrictions No restrictions / (Aggrenox) 7 days 2 hours± (Angiomax) aPTT < 40 seconds* 2 hours± clopidogrel (Plavix) 7 days 2 hours± 48 hours (GFR 50 mL/min or more) (Pradaxa) 6 hours 5 days (GFR less than 50 mL/min)* dalteparin (Fragmin) prophylaxis 12 hours* 2 hours± dalteparin (Fragmin) treatment 24 hours* 24 hours (Savaysa) AWAITING ASRA GUIDANCE AWAITING ASRA GUIDANCE enoxaparin (Lovenox) prophylaxis± 12 hours* 2 hours± enoxaparin (Lovenox) treatment± 24 hours* 24 hours (Integrilin) 8 hours* 2 hours± (Arixtra) prophylaxis 4 days* 12 hours fondaparinux (Arixtra) treatment 7 days* 12 hours heparin [daily dose <10,000 units] No restrictions No restrictions heparin [daily dose >10,000 units] aPTT < 40 seconds 2 hours± NSAIDs No restrictions No restrictions (Effient) 7 days 6 hours 6 hours (Xarelto) 3 days* (24 hours if traumatic puncture) (TNKase) 10 days 10 days (Brilinta) 5 days 6 hours (Ticlid) 14 days 2 hours± (Aggrastat) 8 hours* 2 hours± (Coumadin) 4-5 days or INR less than 1.5 2 hours± ± Optimal timing to resume administration not specified in guidelines; 2 hour estimation presumed for adequate * Longer duration of interruption is required in patients with reduced renal function.

DRUGS WHICH LOWER THE SEIZURE THRESHOLD Myelography practice guidelines recommend careful evaluation of medications known to lower the seizure threshold. Guidelines state that prescribers may withhold some of these medications for 48 hours pre- and 24 hours post-myelography. Guidelines do not provide specific recommendations regarding which medications should be withheld for the procedure. 1

Prescribing information for iohexol (Omnipaque) states that which lower the seizure threshold are not recommended for use with Omnipaque. The prescribing information emphasizes phenothiazine derivatives, including those used for antihistamine properties, MAO inhibitors, tricyclic , CNS , and psychoactive drugs described as analeptics, major tranquilizers, or drugs. 4 1 | P a g e Revised 4/2015

Both guidelines and prescribing information point out that the contributory role of these medications has not been established and that the use of such drugs should be based on the prescriber’s evaluation of potential benefits and potential risks. 1,4

The following table includes medications from classes emphasized in prescribing information that may decrease the seizure threshold. This list does not include all medications with the potential to decrease seizure threshold.

Antidepressants/ /Tranquilizers CNS Stimulants (Elavil) aripiprazole (Abilify) aminophylline (Norphyl, amoxapine (Asendin) asenapine (Saphris) Truphylline) bupropion (Wellbutrin, Zyban, (Thorazine) ammonia (Aromatic Ammonia) Budeprion) clozapine (Clozaril) amphetamine (Evekeo) buspirone (Buspar) droperidol (Inapsine) benzphetamine (Didrex) clomipramine (Anafranil) fluphenazine (Prolixin, Permitil) dexmethylphenidate (Focalin) desipramine (Norpramin) haloperidol (Haldol) dextroamphetamine (Dexedrine) doxepin (Silenor, Sinequan, Zonalon) loxapine (Loxitane) dextroamphetamine/amphetamine duloxetine (Cymbalta) lurasidone (Latuda) (Adderall) (Prozac) mesoridazine (Serentil) diethylpropion (Tenuate) fluvoxamine (Luvox) olanzapine (Zyprexa) doxapram (Dopram) hydroxyzine (Vistaril, Atarax) paliperidone (Invega) lisdexamfetamine (Vyvanse) imipramine (Tofranil) perphenazine (Trilafon) methamphetamine (Desoxyn) maprotiline (Ludiomil) pimozide (Orap) methylphenidate (Ritalin, meprobamate (Miltown, Trancot) prochlorperazine (Compazine) Metadate, Concerta, Daytrana, milnacipran (Savella) promethazine (Phenergan) Methylin) mirtazapine (Remeron) quetiapine (Seroquel) pemoline (Cylert) nefazodone (Serzone) risperidone (Risperdal) phendimetrazine (Bontril, Melfiat, nortriptyline (Aventyl, Pamelor) thiethylperazine (Torecan) Prelu-2) paroxetine (Paxil) thioridazine (Mellaril) phenmetrazine (Picrotoxon, protriptyline (Vivactil) thiothixene (Navane) Preludin) sertraline (Zoloft) trifluoperazine (Stelazine) phentermine (Ionamin, Adipex, trazodone (Desyrel, Oleptro) triflupromazine (Vesprin) Suprenza) trimipramine (Surmontil) trimethobenzamide (Tigan) theophylline (Theo-Dur, Theo-24) vilazodone (Viibryd) ziprasidone (Geodon) vortioxetine (Brintellix) MAO Inhibitors Combinations Miscellaneous isocarboxazid (Marplan) chlordiazepoxide/amitriptyline tramadol (Ultram, Ultracet, Ryzolt) isoniazid (Nydrazid) (Limbitrol) meperidine (Demerol) (Zyvox) perphenazine/amitriptyline (Etrafon, cyclobenzaprine (Flexeril) phenelzine (Nardil) Triavil) varenicline (Chantix) procarbazine (Matulane) naltrexone and buproprion (Contrave) rasagiline (Azilect) promethazine and codeine selegiline (Eldepryl, Zelapar, Emsam) promethazine and dextromethorphan tranylcypromine (Parnate) promethazine and phenylephrine (Promethazine VC) 1 American College of Radiology. ACR-ASNR-SPR practice parameter for the performance of myelography and cisternography. ACR Practice Parameters and Technical Standards. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Myelography.pdf .

2 Horlocker TT, et al. Regional anesthesia in the patient receiving or thrombolytic : American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010 Jan-Feb;35(1):64-101.

3 Horlocker TT, et al. ASRA Anticoagulation 3rd edition Interim update with draft guidance. American Society of Regional Anesthesia and Pain Medicine. https://www.asra.com/advisory-guidelines/article/1/anticoagulation-3rd-edition .

4 GE Healthcare. Omnipaque (iohexol) prescribing information. http://www3.gehealthcare.com/~/media/documents/us- global/products/contrast-media_non-gatekeeper/clinical-product-information/omnipaque/gehealthcare_omnipaque-prescribing- information.pdf .

2 | P a g e Revised 4/2015