[Frequency of the bleeding risk in patients receiving warfarin submitted to arthrocentesis of the knee]

To stop or not to stop novel oral anticoagulants prior to performing joint interventional maneuvers? Evidence from a prospective study that the therapy can be maintained

Anticoagulation is common in patients undergoing routine musculoskeletal interventional maneuvers. Previous retrospective studies have established the safety of continuing anticoagulation with novel oral anticoagulants (NOACs) when performing this kind of interventions. Indeed, ultrasound (US)-guided interventional maneuvers have shown a superior safety profile compared to blind anatomical maneuvers. To evaluate prospectively the periprocedural bleeding events in NOAC-anticoagulated patients undergoing interventional articular or periarticular procedures. Consecutive patients diagnosed with inflammatory or degenerative rheumatologic pathology requiring interventional maneuvers were prospectively recruited. Group 1 was treated with NOACs, group 2 was treated with vitamin K antagonists, and group 3 was not anticoagulated. Prior to the international maneuver, NOAC therapy was continuously administered, in regimens dictated by the underlying anticoagulation indication. Demographics, comorbidities, laboratory parameters, locally administered medication (corticosteroids or viscosupplementation), interventional maneuver location, needle size, and local bleeding events were recorded. Post-procedural control was performed at 30 min, 48 h, and 7 days. No articular/periarticular bleeding event occurred in patients treated with NOACs, regardless of their type and dosage, locally administered medication, needle size, location, and number of interventions per individual. Several patients in all groups developed small superficial ecchymoses at the injection site. Our results suggest that NOACs are safe to be used in a continuous regimen prior to US-guided injections, even as dual antithrombotic therapy (in combination with aspirin). The use of lower gauge needles, chosen for viscosupplementation therapy, was not burdened with adverse effects on the procedural outcome. Key Points • Currently, no prospective studies have been performed to establish the safety of continuous NOAC anticoagulation when performing routine intra- or periarticular interventional maneuvers. • The study offers an extensive view on a wide spectrum of intra- and periarticular interventional maneuvers including anatomic targets and needle sizes that were not previously assessed. • The study offers a perspective into performing repetitive maneuvers in the same patient, both over a short time and at longer intervals. • The zero periprocedural bleeding risk observed in our study may reassure practitioners and suggest that US-guided interventional therapeutic interventions are safe in patients treated with a continuous regimen of different NOACs.

Peri-procedural management and incidence of bleeding events following musculoskeletal injections or aspirations in people on oral anticoagulation and antiplatelet therapy

BACKGROUND

Corticosteroid injections and aspirations are common interventions for managing musculoskeletal and inflammatory conditions. However, there remains limited safety evidence to support injection decisions and peri-procedural management in people on anti-thrombotics, particularly for direct oral anticoagulants (DOACs).

OBJECTIVES

To investigate peri-procedural management and bleeding complications following musculoskeletal injections or aspirations with anti-thrombotic medication use.

DESIGN

A prospective observational study was undertaken (October 2018-December 2020) in Orthopaedics, Rheumatology and Radiology specialities in two large UK healthcare providers. Data collection involved weekly identification of musculoskeletal procedures, emergency attendance or admission within 30 days and follow-up questionnaires sent within 2 weeks post-procedure. Descriptive statistics were used to analyse anticoagulant/anti-platelet use, peri-procedural management and bleeding complications.

RESULTS

Of 5080 procedures, 237 of 1338 responses reported antithrombotic use: warfarin (n = 36), DOACs (n = 75) and antiplatelets (n = 126). There were no self-report or electronic identification of clinically significant bleeding events/complications. Only local bruising was reported (8.6% vs. 0.2% with non-use), and only with medication continuation or international normalised ratio (INR) levels ≥3.8 or unknown. Only 3/72 DOAC use was interrupted.

CONCLUSIONS

In this study, no clinically significant bleeding events or complications were reported or identified following musculoskeletal injections or aspirations, with only localised bruising reported. It was not universal practice to check INR levels and DOAC interruption was uncommon. Findings add evidence that musculoskeletal procedures appear to be low risk procedures for bleeding complications with antithrombotic continuation and when INR levels within lower target range. Research on intra-articular or soft tissue iatrogenic consequences would add to risk/benefit evaluations.

Bleeding complications in patients on warfarin undergoing joint injection/aspiration: systematic review and meta-analysis

Steroid injections in joints are commonly administered for the management of inflammatory or degenerative conditions. There is substantial controversy as to whether to continue warfarin when undertaking joint injection or aspiration. To assess the rate of bleeding complications in patients on warfarin undergoing joint injection/aspiration. Systematic review and meta-analysis. A literature search of 3 online databases was conducted by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study that reported bleeding complication rates in adult patients on warfarin undergoing a joint injection/aspiration whilst taking warfarin anticoagulation. Studies reporting on less than 5 patients were excluded. Meta-analysis was conducted using a random effects model. The search of databases resulted in a total of 1547 articles. After screening, 8 articles were deemed suitable for inclusion in the analysis, involving 871 injection/aspiration procedures. There were only 5 reported cases of bleeding. On meta-analysis the estimated bleeding complication rate was 1.5% (95% CI 0.5-4.5%). This meta-analysis shows that it is safe to perform joint injection and aspiration in patients on warfarin without routine prior testing of INR. Level of evidence: Level 4.

Management of Haemarthrosis in Patients On Oral Anticoagulants

Aims

Our aim was to investigate the management of patients who were admitted to hospital with an acute haemarthrosis whilst taking oral anticoagulants, and highlight the outcomes of different management strategies.

Methods

A retrospective review was performed of all orthopaedic admissions over a 42-month period (January 2015–July 2018) to the Orthopaedic Department of a London District General Hospital. All patients admitted with a spontaneous joint haemarthrosis and concomitant use of oral anticoagulants was identified. Anonymised data was placed on a secure trust database.

Findings

A total of 31 patients were included. 22 patients (71%) had their anticoagulant temporarily held during admission. 9 patients (32%) had their anticoagulation reversed with 10 mg of vitamin K. 5 patients had their haemarthrosis aspirated either on admission or during their hospital stay. The overall mean length of stay in patients with a haemarthrosis was 7.0 days. The mean length of stay in patients who had their anticoagulation held was 8.6 days. In contrast, patients who continued taking their anticoagulation were found to have an average length of stay of 2.3 days. No patients suffered a thrombotic event in the 60 days following discharge. No adverse events were recorded following joint aspiration.

Conclusion

There is currently no consensus on the management of haemarthrosis in patients on oral anticoagulants. Continuing the anticoagulants did not increase length of hospital stay. Further research may focus on assessing the effect of management adjuncts on patient outcomes and their cost effectiveness to aid the development of local and/or national guidelines.

Determination of a safe INR for joint injections in patients taking warfarin

INTRODUCTION

With an increase in life expectancy in 'developed' countries, the number of elderly patients receiving joint injections for arthritis is increasing. There are legitimate concerns about an increased risk of thromboembolism if anticoagulation is stopped or reversed for such an injection. Despite being a common dilemma, the literature on this issue is scarce.

METHODS

We undertook 2,084 joint injections of the knee and shoulder in 1,714 patients between August 2008 and December 2013. Within this cohort, we noted 41 patients who were taking warfarin and followed them immediately after joint injection in the clinic or radiology department, looking carefully for complications. Then, we sought clinical follow-up, correspondence, and imaging evidence for 4 weeks, looking for complications from these joint injections. We recorded International Normalised Ratio (INR) values before injection.

RESULTS

No complications were associated with the procedure after any joint injection. The radiologists who undertook ultrasound-guided injections to shoulders re-scanned the joints looking for haemarthroses: they found none. A similar outcome was noted clinically after injections in the outpatient setting.

CONCLUSION

With a mean INR of 2.77 (range, 1.7-5.5) and a maximum INR within this group of 5.5, joint injections to the shoulder and knee can be undertaken safely in primary or secondary care settings despite the patient taking warfarin.