Anticoagulation and bone marrow biopsy: is it safe to proceed?

Abstract

Background: Bone marrow (BM) biopsy is the most common diagnostic procedure in hematology. Bleeding is an expected complication, and its risk is assumed to be increased in patients on anticoagulants. However, the effect of anticoagulation on BM biopsy safety is unclear and guidelines are lacking robust data in this regard. As such, physicians use their clinical judgement to guide periprocedural management of anticoagulation. objective: To provide the best available evidence regarding management of anticoagulation in patients who need BM biopsy. Methods: We reviewed and summarized available guidelines directing management of periprocedural anticoagulation for BM biopsy, and share our experience and practices with BM biopsy at our institution. Results: The incidence of significant hemorrhage after BM biopsy is very low (0.007-1.1%). BM biopsy is classified as having a low to moderate bleeding risk. Interrupting anticoagulation is not consistently recommended. Strategies exist to minimize bleeding risk for anticoagulated patients. Patients with myeloproliferative neoplasms can develop an acquired von Willebrand syndrome which increases their risk for bleeding and therefore require extra vigilance to ensure appropriate hemostasis. Conclusion: Withholding anticoagulation prior to BM biopsy is not routinely recommended. Instead, assessment and optimization of bleeding risk factors should be done on a patient by patient basis.

Peri‐procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH

“…20 Recently, a retrospective Canadian study analyzed a cohort of 3552 patients undergoing bone marrow biopsy between 2010 and 2020 with 13% of patients receiving anticoagulation, 32% on antiplatelet agents, and 5.5% on both antiplatelet and anticoagulant agents. 21 Anticoagulants and antiplatelet agents were not routinely withheld prior to biopsy. Only one major bleeding event (0.03%) was recorded in a patient with essential thrombocytosis and a platelet count of >1200 x 10 9 /L at the time of biopsy.…”

Value of hemophagocytosis in the diagnosis of hemophagocytic lymphohistiocytosis in critically ill patients

“…14 Furthermore, the procedure is invasive and carries some risk of bleeding. 15 In clinical practice, waiting for BM results often unnecessarily prolongs the diagnostic process. Since early recognition of HLH and swift initiation of immunosuppressives are crucial to the patient's outcome, 4 this approach can be problematic and may be a contributor to the high lethality of the syndrome in critically ill patients.…”

“…Depending on the institutional capabilities, logistics for BM diagnostics may require external validation, leading to time delay and uncertainty regarding interrater variability 14 . Furthermore, the procedure is invasive and carries some risk of bleeding 15 . In clinical practice, waiting for BM results often unnecessarily prolongs the diagnostic process.…”