Saint Francis Health System Department of Radiology MYELOGRAPHY: Medications to be evaluated prior to myelography. ANTICOAGULATION Myelography practice guidelines require discontinuation of anticoagulants prior to the procedure in order to avoid serious adverse events from lumbar puncture in the presence of bleeding risk. Ideally, the decision to discontinue anticoagulants should be made after discussion with that medication’s prescriber. Bridging with intravenous heparin 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 abciximab (Reopro) 48 hours 2 hours± alteplase (Activase, t-PA) full dose 10 days 10 days alteplase (Cathflo Activase) 2mg dose No restrictions No restrictions apixaban (Eliquis) 3 days* 6 hours argatroban aPTT < 40 seconds 2 hours± aspirin (Ecotrin) No restrictions No restrictions aspirin/dipyridamole (Aggrenox) 7 days 2 hours± bivalirudin (Angiomax) aPTT < 40 seconds* 2 hours± clopidogrel (Plavix) 7 days 2 hours± 48 hours (GFR 50 mL/min or more) dabigatran (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 edoxaban (Savaysa) AWAITING ASRA GUIDANCE AWAITING ASRA GUIDANCE enoxaparin (Lovenox) prophylaxis± 12 hours* 2 hours± enoxaparin (Lovenox) treatment± 24 hours* 24 hours eptifibatide (Integrilin) 8 hours* 2 hours± fondaparinux (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 prasugrel (Effient) 7 days 6 hours 6 hours rivaroxaban (Xarelto) 3 days* (24 hours if traumatic puncture) tenecteplase (TNKase) 10 days 10 days ticagrelor (Brilinta) 5 days 6 hours ticlopidine (Ticlid) 14 days 2 hours± tirofiban (Aggrastat) 8 hours* 2 hours± warfarin (Coumadin) 4-5 days or INR less than 1.5 2 hours± ± Optimal timing to resume anticoagulant administration not specified in guidelines; 2 hour estimation presumed for adequate hemostasis * 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 drugs 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 antidepressants, CNS stimulants, and psychoactive drugs described as analeptics, major tranquilizers, or antipsychotic 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 drug 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/Anxiolytics Antipsychotics/Tranquilizers CNS Stimulants amitriptyline (Elavil) aripiprazole (Abilify) aminophylline (Norphyl, amoxapine (Asendin) asenapine (Saphris) Truphylline) bupropion (Wellbutrin, Zyban, chlorpromazine (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) fluoxetine (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) linezolid (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 antithrombotic or thrombolytic therapy: 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 .