The management of patients on antithrombotic therapy undergoing regional anaesthesia is critical to balancing bleeding risk and thromboembolic complications. This article reviews the ASRA and ESAIC/ESRA guidelines for perioperative anticoagulation management. Direct oral anticoagulants (DOACs), vitamin K antagonists, and heparins require specific timing adjustments before and after neuraxial procedures to minimize the risk of spinal haematoma. Key considerations include renal function, drug half-life, procedural complexity, and individual bleeding risk. Ultrasound guidance, alternative peripheral nerve blocks, and vigilant neurological monitoring enhance safety. Multidisciplinary decision-making ensures optimal patient outcomes when anticoagulation cannot be completely withheld.