Several categories of medications and supplements need to be stopped before an epidural injection, primarily because they increase bleeding risk in the spinal area. The most important are blood thinners, anti-inflammatory pain relievers, and certain herbal supplements. Each has a different timeline, so preparation typically starts one to two weeks before your procedure date.
Why Bleeding Risk Matters So Much
The spinal canal contains a network of veins that lack protective valves, making them vulnerable to bleeding. When a needle is placed for an epidural, even a small amount of uncontrolled bleeding can form a clot called a spinal epidural hematoma. This clot presses on the spinal cord or nerves and, if not treated quickly, can cause lasting damage.
Roughly one-quarter to one-third of all spinal hematoma cases are linked to blood-thinning medications. The overall risk is low (historically estimated at less than 1 in 150,000 epidural placements), but it rises sharply in certain groups. In older women undergoing orthopedic procedures, for example, one study found the rate jumped to as high as 1 in 1,000. Stopping the right medications at the right time is the single most effective way to keep this risk near zero.
Blood Thinners: The Longest Lead Times
Prescription anticoagulants require the longest stop times because they powerfully suppress your body’s clotting ability. Based on Stanford Medicine’s guidelines for spinal procedures, here are the typical timelines:
- Warfarin (Coumadin): 4 to 5 days before the procedure
- Clopidogrel (Plavix): 5 to 7 days before
- Apixaban (Eliquis): 3 days before
- Rivaroxaban (Xarelto): 3 days before
These timelines give each drug enough time to clear your system so that normal clotting function returns. Your doctor may also order a blood test on the day of the procedure to confirm your clotting levels are in a safe range, particularly if you take warfarin. Never stop a prescribed blood thinner without your prescribing doctor’s knowledge, since these medications are usually protecting you from stroke or blood clots elsewhere in the body. The two doctors (your prescriber and the one performing the injection) will coordinate the safest plan.
NSAIDs and Over-the-Counter Pain Relievers
Common pain medications you can buy without a prescription also thin the blood enough to matter. During the week before your epidural, you will typically be asked to stop:
- Aspirin (including low-dose “baby” aspirin)
- Ibuprofen (Advil, Motrin)
- Naproxen (Aleve)
These drugs work by blocking substances in your body that help platelets clump together to form clots. Aspirin’s effect on platelets is irreversible for the life of each platelet cell, which is why it needs a full week to wash out. Ibuprofen and naproxen have shorter-acting effects but are still held for the same general window to be safe. If you need pain relief during that waiting period, acetaminophen (Tylenol) is generally considered safe because it does not affect clotting.
Herbal Supplements and Vitamins
Several popular supplements carry hidden bleeding risks that many people don’t realize. Cleveland Clinic recommends stopping all non-essential supplements two weeks before a procedure. The ones most commonly flagged for bleeding risk include:
- Fish oil (omega-3 fatty acids)
- Vitamin E
- Ginkgo biloba
- Garlic supplements (concentrated capsules, not dietary garlic in food)
These supplements don’t thin the blood as aggressively as prescription anticoagulants, but they can add up, especially if you’re taking more than one or combining them with an NSAID you forgot to mention. Bring a full list of everything you take, including vitamins and supplements, to your pre-procedure appointment so nothing gets overlooked.
Diabetes Medications
If you take metformin (sometimes sold as Glucophage), many clinics ask you to stop it 24 hours before and 24 hours after the injection. This precaution relates to how metformin interacts with contrast dye and fasting, not to bleeding risk.
There’s another important consideration for anyone with diabetes: epidural steroid injections can raise blood sugar significantly for two to three days afterward. Check your levels before the appointment and monitor them closely in the days that follow. You may need temporary adjustments to your insulin or other diabetes medications, so let the doctor who manages your diabetes know you’re having this procedure.
Food and Drink on Procedure Day
If your epidural involves any sedation (even mild “twilight” sedation), you’ll need to fast beforehand. Standard guidelines allow solid food up to 8 hours before your scheduled arrival time. Clear liquids like water, black coffee, apple juice, and sports drinks like Gatorade are typically fine up to 2 hours before arrival. Milk, cream, and smoothies count as solids, not liquids, so they follow the 8-hour rule.
Not every epidural injection requires sedation. Many are done with only a local numbing injection at the skin. If that’s your situation, fasting restrictions may not apply, but confirm this with your clinic ahead of time.
Medications You Should Keep Taking
A common source of confusion is whether to hold your regular medications on procedure day. For most prescriptions, including blood pressure and heart medications, the standard instruction from Kaiser Permanente and similar systems is to take them as usual with a small sip of water, even if you’re fasting. Skipping a blood pressure medication, for instance, could cause a dangerous spike during the procedure.
The exceptions are the blood thinners, NSAIDs, certain diabetes medications, and supplements already described. If you’re unsure about a specific medication, call your procedure clinic a few days in advance rather than guessing on the morning of your appointment.
A Practical Timeline
Putting it all together, your preparation schedule looks roughly like this:
- 2 weeks before: Stop herbal supplements and non-essential vitamins (fish oil, vitamin E, ginkgo, garlic capsules)
- 5 to 7 days before: Stop clopidogrel (Plavix) if directed by your doctor
- 4 to 5 days before: Stop warfarin if directed
- 3 days before: Stop apixaban (Eliquis) or rivaroxaban (Xarelto) if directed
- 7 days before: Stop aspirin, ibuprofen, and naproxen
- 24 hours before: Stop metformin
- 8 hours before: Stop eating solid food (if sedation is planned)
- 2 hours before: Stop clear liquids (if sedation is planned)
- Morning of: Take your regular blood pressure and heart medications with a sip of water
Your clinic will give you personalized instructions, and those always take priority over general guidelines. The most important thing you can do is provide a complete, honest medication and supplement list well before your procedure date so nothing falls through the cracks.