Block and Load: The ASRA’s Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy – 5th edition

The administration of regional anesthesia in patients receiving anticoagulant or antithrombotic therapy necessitates adherence to evidence-based guidelines to mitigate the risk of perioperative hemorrhagic complications.
The American Society of Regional Anesthesia and Pain Medicine (ASRA) published its fifth edition of evidence-based guidelines in 2025, significantly updating prior recommendations with novel insights and refined classifications.¹
The ESRA newsletter editors have thoroughly examined the newly released ASRA guidelines¹ and provide a concise overview of their key updates. However, for a comprehensive understanding and optimal clinical application, readers are encouraged to delve into the full guidelines and integrate their insights into practice.

The ASRA’s anticoagulation 2025 guidelines incorporate several key updates, including a revised risk stratification model, new pharmacokinetic considerations, and expanded recommendations for direct oral anticoagulants (DOACs). The transition from “prophylactic” and “therapeutic” terminology to “low dose” and “high dose” anticoagulant classifications aligns ASRA’s guidance with other international standards, including ESAIC/ESRA guidelines,² facilitating clinical application. Additionally, this new 5^th edition integrates recommendations for laboratory monitoring, acknowledging the growing role of drug-specific assays in perioperative decision-making.
Another significant revision in the ASRA’s anticoagulation 2025 guidelines pertains to the timing of anticoagulant discontinuation. Recognizing the pharmacokinetic variability of DOACs and the increased availability of real-time drug monitoring, ASRA introduces individualized interruption timelines based on renal function and patient-specific thrombosis risk. Moreover, the guidelines now distinguish between neuraxial and deep plexus/peripheral blocks with a more precise classification.
The ASRA guidelines also emphasize the management of antiplatelet therapy, particularly in patients on P2Y12 inhibitors and includes an updated guidance on reversal strategies for vitamin K antagonists and DOACs, incorporating new reversal agents where applicable.

«These new recommendations enhance patient safety while allowing for greater procedural specificity in select cases.»

Comparison with ESAIC/ESRA 2022 Guidelines. While both ASRA and ESAIC/ESRA categorize regional anesthesia procedures based on bleeding risk, ESAIC/ESRA provides a more detailed, block-specific and patient-centered approach that integrates bleeding risk scores, whereas ASRA maintains a conservative, standardized framework.
ESAIC/ESRA places greater emphasis on real-time reversal strategies, whereas ASRA prioritizes predefined interruption intervals and structured management algorithms.
Despite these differences, both guidelines recognize the importance of renal function in anticoagulant management, share core principles, including the prioritization of patient safety, the necessity of anticoagulant discontinuation before high-risk procedures, and the need for clinician education on evolving pharmacologic agents.

The ASRA’s anticoagulation 2025 guidelines represent a significant advancement in the management of anticoagulated patients undergoing regional anesthesia. By incorporating pharmacokinetic modeling, drug-specific assays, and tailored discontinuation strategies, ASRA provides clinicians with a more refined decision-making framework. These new recommendations enhance patient safety while allowing for greater procedural specificity in select cases. The integration of structured reversal strategies and expanded DOAC guidance ensures that practitioners are equipped with the latest evidence-based protocols.

With the increasing complexity of anticoagulation management, these updates will have a profound impact on clinical practice. By offering clearer classifications, embracing real-time laboratory assessments, and refining discontinuation protocols, ASRA’s anticoagulation guidelines 2025 enhances the precision of regional anesthesia planning. Ultimately, these changes will facilitate improved patient outcomes, minimizing the risk of perioperative bleeding while maintaining effective thromboprophylaxis.

1. 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 [Internet] 2025; rapm-2024-105766 Available from: https://rapm.bmj.com/lookup/doi/10.1136/rapm-2024-105766
2. Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol Lippincott Williams and Wilkins; 2022; 39: 100–32