International Journal of Health & Allied Sciences

LETTER TO EDITOR
Year
: 2014  |  Volume : 3  |  Issue : 1  |  Page : 73--74

Should we stop cilostazol before central neuraxial blockade?


Abhijit S Nair 
 Department of Anesthesiology, Yashoda Superspeciality Hospital, Somajiguda, Hyderabad, Andhra Pradesh, India

Correspondence Address:
Abhijit S Nair
Department of Anesthesiology, Yashoda Superspeciality Hospital, Rajbhavan Road, Somajiguda, Hyderabad 500 082, Andhra Pradesh
India




How to cite this article:
Nair AS. Should we stop cilostazol before central neuraxial blockade?.Int J Health Allied Sci 2014;3:73-74


How to cite this URL:
Nair AS. Should we stop cilostazol before central neuraxial blockade?. Int J Health Allied Sci [serial online] 2014 [cited 2020 Mar 28 ];3:73-74
Available from: http://www.ijhas.in/text.asp?2014/3/1/73/130627


Full Text

Sir,

Cilostazol is a selective phosphodiesterase III inhibitor with reversible antiplatelet action. It causes dilatation of the arteries supplying blood to the legs by inhibiting calcium induced contraction of smooth muscle cells and also inhibits platelet aggregation. This antiplatelet action is more potent than Aspirin. Cilostazol is indicated in patients with intermittent claudication due to peripheral vascular disease. It is also used in patients with coronary artery disease, patients having stented coronaries who develop in-stent stenosis with routine dual antiplatelet medications (Aspirin and Clopidogrel), in patients with graft blockage after coronary artery bypass grafting with the routine antiplatelet medications and at times in patients with cerebrovascular disease. [1],[2],[3]

Molecular formula: C 20 H 27 N 5 O 2 .

Chemically it is: 6-(4-[1-cyclohexyl-1H-tetrazol-5-yl]-butoxy)-3, 4-dihydro-carbostyri.

[INLINE:1]

 Chemical Structure of Cilostazol



Risk of bleeding increases with simultaneous use of antiplatelets and oral anticoagulants. [4] Even use of non-steroidal anti-inflammatory drugs along with cilostazol can lead to bleeding issues in the perioperative period. Due to reversible antiplatelet action and short half-life (11-13 h) of Cilostazol, risk of surgical bleeding is less and regional anesthesia can be safely administered if Cilostazol is stopped atleast 72 h prior to surgery. [5],[6]

Before stopping an antiplatelet agent before surgery, risks and benefits have to be weighed. General anesthesia can be planned if it is not justified to stop antiplatelets before surgery (presence of coronary stent etc.). Hall and Mazer described about the perioperative problems with ongoing aspirin, clopidogrel and prasugrel therapy. [4] But nothing other than the pharmacology and relevant interactions of Cilostazol was described. Mercado and Petty suggested that unlike aspirin and clopidogrel, cilostazol can be stopped for 2-3 days only due to its reversible anti-platelet action by virtue of its short half-life. [5] Douketis et al. suggested that ongoing cilostazol therapy should be stopped for at least 2-3 days prior to surgery to reduce the risk of bleeding although no specific recommendation was given for performance of a regional anesthesia technique. [6] Kaneda et al. in their study have reported a case of epidural hematoma from T12-L3 level in a 90-year-old male patient who underwent thrombectomy for lower limb ischemia. [7] Patient underwent an emergency evacuation of hematoma and spinal cord decompression thereafter. This was probably the only case report which describes the possible spinal hematoma that occurred due to regional anesthesia due to ongoing cilostazol therapy. Horlocker et al. published the 3 rd ed. of guidelines for Regional anesthesia in patient receiving antithrombotic or thrombolytic therapy in 2010 where no specific mention has been made about bleeding issues related to the use of cilostazol. [8] Similarly, Gogarten et al. who published recommendations of European Society of Anesthesiology for use of regional anesthesia during concomitant use of antithrombotic agents didn't specify anything about cilostazol. [9] However we feel that in the interest of the patient, cilostazol should be stopped at least 72 h prior to surgery to minimize neuraxial hematomas and avoid catastrophic neurodeficits.

References

1Chi YW, Lavie CJ, Milani RV, White CJ. Safety and efficacy of cilostazol in the management of intermittent claudication. Vasc Health Risk Manag 2008;4:1197-203.
2Douglas JS Jr, Holmes DR Jr, Kereiakes DJ, Grines CL, Block E, Ghazzal ZM, et al. Coronary stent restenosis in patients treated with cilostazol. Circulation 2005;112:2826-32.
3Uchiyama S, Demaerschalk BM, Goto S, Shinohara Y, Gotoh F, Stone WM, et al. Stroke prevention by cilostazol in patients with atherothrombosis: Meta-analysis of placebo-controlled randomized trials. J Stroke Cerebrovasc Dis 2009;18:482-90.
4Hall R, Mazer CD. Antiplatelet drugs: A review of their pharmacology and management in the perioperative period. Anesth Analg 2011;112:292-318.
5Mercado DL, Petty BG. Perioperative medication management. Med Clin North Am 2003;87:41-57.
6Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8 th Edition). Chest 2008;133:299S-33S.
7Kaneda T, Urimoto G, Suzuki T. Spinal epidural hematoma following epidural catheter removal during antiplatelet therapy with cilostazol. J Anesth 2008;22:290-3.
8Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, 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;35:64-101.
9Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM, et al. Regional anaesthesia and antithrombotic agents: Recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010;27:999-1015.