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A 70-year-old woman with atrial fibrillation is scheduled for elective total knee arthroplasty with spinal anesthesia. She is taking 5 mg of apixaban twice daily for stroke prevention. According to 2025 guidelines from the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine), what is the MINIMUM recommended interval between the last dose of apixaban and neuraxial intervention?
A. 24 hours X
B. 48 hours X
C. 72 hours ✔
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In 2025, the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) updated both terminology and practice recommendations in their guidelines for patients receiving anticoagulation therapy. In the older guidelines, anticoagulation therapy was classified by purpose—either prophylactic or therapeutic. In the updated guidelines, therapy is now categorized by dosing—either low or high.
The dosing regimen described in the clinical scenario (5 mg of apixaban twice daily) is considered a high-dose regimen even though it is being used for a prophylactic purpose (stroke prevention in nonvalvular atrial fibrillation) (Table 1). Thus, assuming normal renal function, the minimum recommended interval between the last dose of apixaban and neuraxial intervention in this patient is 72 hours. This interval may reduce the risk of hematoma and other adverse bleeding events. In cases where a 72-hour interval is not possible, drug-specific anti-Xa levels (targeting levels < 30 ng/mL) may be considered in lieu of the interval. In general, the ASRA Pain Medicine guidelines are more conservative than other guidelines such as those published by the American College of Chest Physicians, which are focused more on thrombosis prevention.
Table 1. Examples of how 2025 guidelines from the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) apply to various oral anticoagulants. Information from Kopp SL, Vandermeulen E, McBane RD, Perlas A, Leffert L, Horlocker T. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition). Reg Anesth Pain Med. Published online October 17, 2025. doi:10.1136/rapm-2024-105766
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Date of last update: March 25, 2026
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