From the Guidelines
Taking Eloquis (apixaban) is not an absolute contraindication to performing joint injections, but precautions should be taken to minimize bleeding risk. For low-risk peripheral joint injections, such as knee, shoulder, or ankle, it is typically not necessary to discontinue apixaban, as suggested by the guidelines from the American College of Chest Physicians 1. However, for higher-risk injections near neurovascular structures or in the spine, temporary discontinuation of apixaban may be recommended, with the last dose taken 3 days before the procedure, as recommended for high-risk procedures 1. The decision to discontinue apixaban should be individualized based on the patient's thrombotic risk versus bleeding risk, considering factors such as mechanical heart valves, recent venous thromboembolism, or atrial fibrillation with high CHADS2 score, which may require bridging therapy during the interruption period 1. When performing the injection, using smaller gauge needles (22-25G), applying pressure after the procedure, and careful monitoring for bleeding complications are important safety measures, as the risk of bleeding varies significantly based on the specific joint location and technique used 1. It is essential to weigh the benefits of the joint injection against the potential risks and to consider alternative treatments or procedures that may be safer for the patient, as the management of antithrombotic therapy in patients undergoing elective surgeries and invasive procedures is a complex issue that requires careful consideration of multiple factors 1. In general, the most recent guidelines from the American College of Chest Physicians 1 and the British Society of Gastroenterology 1 provide a framework for managing patients on anticoagulant therapy, including those taking apixaban, and should be consulted when making decisions about joint injections in these patients.
From the Research
Safety of Joint Injections in Patients Taking Eloquis (Apixaban)
- The safety of administering joint injections to patients taking Eloquis (apixaban) has been evaluated in several studies 2, 3, 4.
- A systematic review of 668 patients undergoing injections/aspiration procedures while taking novel oral anticoagulants, including apixaban, found that only one patient experienced a bleeding complication, and that patient was taking dabigatran, not apixaban 2.
- Another study found that joint aspiration and injection are safe in patients taking anticoagulants, including apixaban, and that anticoagulation should not be routinely discontinued in these patients 3.
- A meta-analysis of randomized controlled trials found that apixaban was associated with a lower incidence of total wound complications compared to low molecular weight heparins (LMWH) in patients undergoing total joint arthroplasty 4.
Bleeding Risks
- The risk of bleeding complications in patients taking apixaban and undergoing joint injections is considered low 2, 3.
- A study found that apixaban was associated with a reduction in the risk of major/clinically relevant nonmajor bleeding events compared to LMWH in patients undergoing total joint arthroplasty 4.
- However, another study found that rivaroxaban, another novel oral anticoagulant, increased the risk of major/clinically relevant nonmajor bleeding events compared to LMWH 4.
Clinical Implications
- The available evidence suggests that it is relatively safe to administer joint injections to patients taking Eloquis (apixaban) 2, 3.
- However, decisions regarding the management of anticoagulation in patients undergoing joint injections should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3.