From the Research
Botulinum toxin injections can generally be performed safely in patients on anticoagulation therapy, with a low risk of significant bleeding complications, as evidenced by a study published in 2021 1. When considering botulinum toxin injections in patients on anticoagulation therapy, several factors should be taken into account to minimize the risk of bleeding complications.
- The type of anticoagulant being used, such as warfarin, aspirin, or direct oral anticoagulants (DOACs), can impact the risk of bleeding.
- The location and depth of the injection, with deeper or larger volume injections potentially carrying a higher risk of bleeding.
- The use of firm pressure to injection sites for 3-5 minutes to minimize bruising and hematoma formation.
- The use of the smallest gauge needle possible and minimizing the number of injection sites.
- For patients on warfarin, ideally the INR should be within therapeutic range (not supratherapeutic) before proceeding, as supported by studies published in 1995 2 and 1993 3.
- For those on DOACs, scheduling the injection just before the next dose is due can minimize bleeding risk, although the relationship between INR values and anticoagulant activity may be less predictive for apixaban compared to rivaroxaban, as noted in a 2019 study 4. The decision to continue or pause anticoagulation should always balance the risk of thromboembolism against the risk of bleeding, with particular caution in high-risk areas such as periorbital injections where compartment syndrome could occur, as highlighted in a 2018 study 5. Key considerations for minimizing bleeding risk include:
- Using the smallest gauge needle possible
- Minimizing the number of injection sites
- Applying firm pressure to injection sites for 3-5 minutes
- Scheduling injections carefully in relation to anticoagulant dosing
- Monitoring INR values for patients on warfarin to ensure they are within therapeutic range.