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We thank Drs Ghabach, Einhorn, and Vorenkamp for thoughtfully highlighting the inherent challenges in developing guidelines designed to prevent rare complications that are not easily studied.1 2 The ASRA Pain medicine anticoagulation guidelines have always been purposely anti-hemorrhagic and are written conservatively in order to provide guidance that will minimize the risk of hematoma in most instances. We recognize, however, that there are clinical circumstances in which carefully considered deviations from the guidelines may be in the patient’s best interest, even if they involve a modest increase in risk.