The Risk of Bleeding Complications in Intra-Articular Injections and Arthrocentesis in Patients on Novel Oral Anticoagulants: A Systematic Review

Abstract

Novel oral anticoagulants (NOACs) are increasingly prescribed blood-thinning medication. Surpassing Warfarin, NOACs are more favored and extensively used in paroxysmal atrial fibrillation, acute coronary syndrome, and in elderly patients. Well-known benefits of novel oral anticoagulants include predictable pharmacokinetics, pharmacodynamics, and shorter half-life. However, as with any anticoagulant, there are bleeding risks with NOACs. There is a lack of evidence and consensus on the management of novel anticoagulants for intraarticular injections and arthrocentesis. This systematic review aims to analyze the risk of bleeding complications in patients on novel oral anticoagulants who underwent joint injections and arthrocentesis to help physicians in the decision-making and consenting process. A literature search of three online databases was completed using the Cochrane methodology for systematic reviews. Eligibility criteria included any study that reported bleeding complication rates in adult patients on novel oral anticoagulants that had a joint injection or aspiration whilst continuing their regular oral anticoagulation. All studies with any number of patients and published in any language were included. Review articles and systematic reviews were excluded. The search of databases resulted in a total of 310 articles. After screening, a total of four articles were deemed suitable to be included in the analysis. These described a total of 668 patients undergoing injections/aspiration procedures with patients on three different novel oral anticoagulants namely Rivaroxaban, Apixaban, and Dabigatran. Only one patient joint had a bleeding complication and the patient was on Dabigatran. The results of this systematic review show that it is relatively safe to perform joint injections and arthrocentesis whilst continuing on Novel oral anticoagulation.

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

“…A study of 117 procedures with dagabigatran continuation reported one haemarthrosis (Guillen-Astete et al, 2017). The current study adds to this accumulating evidence of safety that continuation of DOACs is a low risk strategy with musculoskeletal procedures against the risks with interruption (Brennan et al, 2019;Kotecha et al, 2022;Tarar et al, 2021).…”

“…With direct oral anticoagulant (DOAC) therapy, there is much less specific safety evidence for peri‐procedural management with musculoskeletal procedures (Kotecha et al., 2022; Tarar et al., 2021). There is additional complexity in that unlike warfarin, the anticoagulant effects of DOACs cannot be easily or reliably assessed in a clinical context (Dubois et al., 2017).…”

“…With direct oral anticoagulant (DOAC) therapy, there is much less specific safety evidence for peri-procedural management with musculoskeletal procedures (Kotecha et al, 2022;Tarar et al, 2021).…”

“…With growing observational evidence, musculoskeletal injections are being increasingly considered as minimal or low risk procedures across the guidance literature and unlikely to result in a significant bleeding event for people on anticoagulation and antiplatelet therapy (Kotecha et al., 2022; Tarar et al., 2021). Rheumatology guidance offers an estimated bleeding risk of between 0% and 2% (Uson et al., 2021).…”

EUROVISCO Good Practice Recommendations for a First Viscosupplementation in Patients with Knee Osteoarthritis

“…The knee is not considered to be a “deep” joint and an AI may be performed without the need to temporarily withdraw anticoagulant treatment. 35,36 HA, in contrast to the NSAIDs, does not induce an increased risk of bleeding, and therefore VS may be considered safe in these patients. The patient must, however, be warned of the risk of a skin hematoma at the point of injection.…”