Updated MAR 26, 2013 Myelography Seizures:

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1 Updated MAR 26, 2013 Myelography Medications to be evaluated prior to myelography. This list is to assist the radiologist, pharmacist, and radiology technologist in evaluating medication risk associated with myelography. This list is not designed to be exhaustive and should be used with good clinical judgment. Seizures: Focal and generalized motor seizures have been reported after intrathecal use of water soluble contrast agents. In several of those cases reported higher than recommended doses were employed. Therefore avoid: Deviations from recommended neuroradiologic procedure or patient management. Use in patients with a history of epilepsy unless medically justified. Overdosage. Intracranial entry of a bolus or premature diffusion of a high concentration of the medium Failure to maintain elevation of the head during the procedure, on the stretcher, and in bed. Excessive and particularly active patient movement or straining Drugs associated with seizures: Carefully evaluate the patient s medication profile and consider holding these medications for 48 hours prior and 24 hours after the myelogram. This list is limited to agents mentioned in the package insert for intrathecal contrast media. Though not contraindicated, these drugs should be carefully evaluated. Phenothiazines, including those used for their antihistaminic properties; tricyclic antidepressants; MAO inhibitors; CNS stimulants; analeptics; antipsychotic agents. Also the drug must have a documented incidence of seizures of greater than 0.4%. Refer to contrast media package insert for specific warning. 1

2 Antidepressants/Antianxiety Adapin - doxepin amitriptyline - Elavil, Endep amoxapine - Asendin Anafranil - clomipramine Asendin amoxapine Aventyl nortriptyline Budeprion bupropion bupropion Wellbutrin, Zyban, Budeprion Buspar buspirone buspirone - Buspar clomipramine - Anafranil desipramine - Norpramin doxepin - Sinequan, Adapine Elavil, Endep amitriptyline fluoxetine - Prozac imipramine - Tofranil Ludiomil maprotiline maprotiline - Ludiomil Norpramin - desipramine nortriptyline - Pamelor nortriptyline - Aventyl Pamelor nortriptyline protriptyline - Vivactil Prozac fluoxetine Sinequan doxepin Surmontil trimipramine Tofranil - imipramine trimipramine - Surmontil Vivactil protriptyline Wellbutrin - bupropion Zyban - bupropion Combination Tranquilizer and Antidepressant chlordiazepoxide & amitriptyline - Limbitrol Etrafon perphenazine & amitriptyline Limbitrol chlordiazepoxide & amitriptyline perphenazine & amitriptyline - Etrafon perphenazine & amitriptyline - Triavil Triavil perphenazine & amitriptyline Drugs with MAO Inhibition Activity Eldedryl, selegiline Emsam - selegiline isocarboxazide - Marplan isoniazid linezolid- Zyvox Marplan isocarboxazide Matulane - procarbazine Nardil phenelzine Parnate tranylcypromine phenelzine - Nardil procarbazine - Matulane rasagiline-azilect selegiline- Eldepryl,, Zelapar, Emsam tranylcypromine - Parnate Zelapar - selegiline Zyvox-linezolid 2

3 CNS Stimulants Adipex-P - phentermine aminophylline - Aminophylline amphetamine - Adderall Adderall amphetamine benzphetamine - Didrex Bontril phendimetrazine Concerta - methylphenidate Cylert pemoline Daytrana methylphenidate Desoxyn methamphetamine Dexedrine dextroamphetamine dextroamphetamine - Dexedrine Didrex benzphetamine diethylpropion - Tenuate Dopram doxapram doxapram - Dopram Ionamin - phentermine lisdexamfetamine- Vyvanse mazindol Sanorex Melfiat-2 - phendimetrazine Metadate methylphenidate methamphetamine Desoxyn Methylin - methylphenidate methylphenidate - Daytrana, Concerta, Metadate, Methylin, Ritalin phendimetrazine - Bontril, Melfiat, Prelu-2 phentermine - Ionamin, Adipex-P Prelu-2 - phendimetrazine Ritalin methylphenidate Sanorex mazindol Tenuate - diethylpropion theophylline- Theo-Dur, Theo-24 Theo-Dur, Theo-24 - theophylline Vyvanse - lisdexamfetamine Antipsychotics Abilify - aripiprazole aripiprazole -Abilify asenapine - Saphris chlorpromazine - Thorazine clozapine Clozaril Clozaril - clozapine Compazine prochlorperazine Fanapt - iloperidone fluphenazine - Prolixin, Permitil Geodon- ziprasidone- Haldol haloperidol haloperidol - Haldol iloperidone -Fanapt Invega paliperidone Latuda - lurasidone lurasidone - Latuda loxapine - Loxitane Loxitane loxapine Mellaril thioridazine Navane thiothixene olanzapine - Zyrexa paliperidone - Invega perphenazine - Trilafon Phenergan promethazine prochlorperazine - Compazine Prolixin, Permitil fluphenazine promethazine - Phenergan quetiapine- Seroquel risperidone- Risperdal Risperdal- risperidone Saphris - asenapine Seroquel- quetiapine Stelazine trifluoperazine thioridazine - Mellaril thiothixene - Navane Thorazine chlorpromazine trifluoperazine - Stelazine Trilafon perphenazine ziprasidone- Geodon Zyrexa- olanzapine Ryzolt tramadol tramadol Ultram, Ultracet, Ryzolt Ultram tramadol Ultracet tramadol Miscellaneous 3

4 Bleeding Risk: Guidelines for Holding Other Antithrombotics for Invasive Procedures Drug Duration for holding Source warfarin(coumadin) Hold approximately 5 days or until INR less than 1.5 enoxaparin* (Lovenox) heparin* fondaparinux (Arixtra) Hold 24 hours prior to procedure and consider half the dose as the last dose prior to the procedure For minor procedure may resume 24 hours after when there is adequate hemostasis for 12 hours For major/high-bleeding risk surgery may resume: therapeutic-dose 24 to 72 hrs after hemostasis is secured; low-dose after hemostasis is secured Treatment doses, 4 hours prior Prophylaxis doses, no need to hold May resume 1 hour after Hold 48 hours if low risk of bleeding Hold 4 days hours if high risk of bleeding Hold 4 to 6 days if CrCl 30 to 50 ml/min Anesth Analg 2007;105:1540 argatroban PTT every 2 hours (when PTT is less than 40) lepirudin (Refludan) PTT every 4 hours (when PTT is less than 40) bivalirudin PTT every 2 hours (when PTT is less than 40) (Angiomax) dabigatran (Pradaxa) apixaban (Eliquis) Hold 24 to 48 hours if CrCl >= 50 ml/min Hold 3 to 5 days if CrCl < 50 ml/min Consider longer hold times if complete hemostasis is required PTT provides an approximation of anticoagulant activity Hold 24 hours prior with low risk of bleeding or where bleeding would be noncritical in location and easily controlled Hold 48 hours prior with moderate or high-risk of unacceptable or clinically significant bleeding rivaroxaban (Xarelto) Hold 24 hours prior aspirin 7 to 10 days prior clopidogrel (Plavix) prasugrel (Effient) 7 to 10 days prior If coronary stent in place consult patient s cardiologist for options AHA/ACC/SCAI/ACS/ADA ticagrelor(brilinta) 18 to 24 hours ticlodipine (Ticlid) Hold 10 to 14 days prior cilostazol (Plental) Hold 2 to 3 days prior NSAIDS Stop 5 half-lives prior abciximab Stop 48 hours prior epifibitide Stop 8 hours prior alteplase Fibrinogen levels may be useful to evaluate residual thrombolytic effects. For catheter clearance (Cathflo ), no time restriction * Consider the anticipated bleeding risk and adequacy of post-operative hemostasis in individual pts to determine the timing of enoxaparin or heparin resumption instead of resuming enoxaparin or heparin at a fixed time after surgery. Regional Anesthesia and Pain Medicine, Vol 35, No 1 (January February), 2010: pp (). Circulation 2007;115:813 (AHA/ACC/SCAI/ACS/ADA). 2012;133:299S-339S (). 4

5 NSAID 5 Half-lives Chart Medication Brand Name Half-life 5 Half-lives diclofenac potassium Cambia, Zipsor, Cataflam diclofenac sodium, immediate release, delayed release, extended-release, topical gel Arthotec Voltaren Solaraze Voltaren Gel diclofenac epolamine patch Flector 12 hours 60 hours ketodolac Lodine 7.5 hours 37.5 hours fenoprofen calcium Nalfon 3 hours 15 hours flurbiprofen Miscellaneous 5.7 hours 28.5 hours ibuprofen Advil Caldolor Motrin indomethacin Indocin 4.5 hours 22.5 hours ketoprofen immediate release Miscellaneous 2 to 4 hours 10 to 20 hours ketoprofen extended release Miscellaneous 5.4 hours 27 hours ketorolac tromethamine Toradol Normal = 5 hours Renal insufficiency = 6 to 19 hours Normal = 25 hours Renal insufficiency = 30 to 95 hours meclofenamate sodium Meclomen 1.3 hours 6.5 hours mefenamic acid Ponstel meloxicam Mobic 15 to 20 hours 75 to 100 hours nabumetone Relafen 22.5 to 39.2 hours to 196 hours naproxen, naproxen delayed release, naproxen sodium Aleve Anaprox Naprosyn EC- Naprosyn 12 to 17 hours 60 to 85 hours oxaprozin Daypro 42 to 50 hours 210 to 250 hours piroxicam Feldene 50 hours 250 hours sulindac Clinoril 7.8 hours 39 hours tolmetin sodium Tolmetin 2 to 7 hours 10 to 35 hours Resources: Facts and Comparisons and package inserts 5