OA43 Peri-procedural management and incidence of bleeding events following musculoskeletal injections and aspirations in people on anticoagulation and antiplatelet therapy
Authors: McCrum Carol , Grainger Sally 
Published: April 2023

Abstract

Background/Aims
Corticosteroid injections and aspirations are common interventions for managing musculoskeletal conditions and inflammatory arthritis. However, there remains limited safety evidence to support safe practice for injection decisions in people on anticoagulant therapy, particularly direct oral anticoagulant (DOAC) medications regarding incidence of bleeding events or complications. Although there is increasing evidence for warfarin continuation, there is considerable variation in published guidance, manufacturer recommendations and specialty approaches to peri-procedural management of DOACs. This study reports on peri-procedural practice regarding continuation or discontinuation, bleeding events and complication rates in people on anticoagulant and antiplatelet medication undergoing musculoskeletal injections.

Methods
A prospective observational study was undertaken (October 2018- December 2020) using weekly electronic database searches to identify musculoskeletal injection and aspiration procedures undertaken in orthopaedics, rheumatology and radiology in two large NHS providers. Reply-paid questionnaires were sent to all consecutive adults within two weeks of procedures. Information was collected on bleeding events/complications, anticoagulant/antiplatelet use, products, doses, indications, INR levels and checking, discontinuation/re-initiation, comorbidities, and other medications. Concurrent electronic searches were also undertaken for emergency attendance or admissions within 30 days following procedures to identify unreported serious bleeding events or complications.

Results
Electronic searching identified 5,080 musculoskeletal procedures with 1,338 (26.3%) respondents (ages 20-99 years) returning questionnaires. 356 received &gt;1 procedure over the timeframe and 49 bilateral procedures. There were 45 reports of bleeding events and all non-clinically significant localised bruising of the skin: 25/1106 (0.2%) without anticoagulation or antiplatelet therapy; 20/232 (8.6%) with anticoagulant/antiplatelet therapy, occurring only with continued medications. Incidences included: warfarin with unknown INR levels (n= 2/36, 5.5%); DOACs (n=9/72, 12.5%) [apixaban (5/24, 21%), rivaroxaban (4/45, 8.8%)]; antiplatelets [clopidogrel (4/28, 14.2%), clopidogrel & NSAID (1/4, 25%), aspirin (1/72, 1.3%), aspirin & NSAID (2/11, 18.1%), NSAID (1/3, 33.3%)]. Localised bruising was more common with DOAC continuation, aspirin with NSAID use, clopidogrel use and older age. Only 3/72 respondents on DOACs reported instructions to interrupt medications (orthopaedics). There were no serious bleeding or thromboembolic events identified through electronic searches for any recipient within 30 days following procedures.

Conclusion
This observational study found no significant bleeding events resulting from musculoskeletal injections or aspirations with continuation of warfarin (INR &lt; 3.80), direct oral anticoagulant use, antiplatelet or combination therapy. The only consequence reported was some occurrence of localised bruising, also reported without medication use. It was not universal practice to determine INR levels prior to procedures with warfarin use and common practice to continue DOACs and antiplatelet medications. This research adds to evidence that musculoskeletal injections and aspirations appear to be very low risk procedures for bleeding complications with continuation of anticoagulant and antiplatelet therapy. Further research on intra-articular or intra-tissue iatrogenic consequences with anticoagulant/antiplatelet use is needed to add to procedural risk/benefit evaluations.
Disclosure
C. McCrum: Grants/research support; Funding grant to provide professional education workshops-Novartis, Janssen. S. Grainger: None.