Management of Blood Thinners Before Steroid Injections in the Back
Blood thinners should be temporarily discontinued before receiving steroid injections in the back to minimize bleeding risk, with specific timing based on the type of anticoagulant. 1
Recommendations by Anticoagulant Type
Warfarin
- Stop warfarin 5 days before the procedure 1
- Check INR prior to procedure to ensure it's below 1.5 1, 2
- For high thrombotic risk patients (mechanical heart valves, recent venous thromboembolism within 3 months), use bridging therapy with LMWH 1
- Resume warfarin the evening of the procedure if hemostasis is adequate 1
Direct Oral Anticoagulants (DOACs)
- Stop DOACs at least 48 hours before the procedure 1
- For patients on dabigatran with reduced renal function (CrCl 30-50 mL/min), stop 72 hours before the procedure 1
- Consult a hematologist for patients with rapidly deteriorating renal function 1
Antiplatelet Agents
- Low-dose aspirin (75-100 mg) can generally be continued for low-risk procedures 1
- For high-risk procedures, aspirin may need to be discontinued 1
- P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) should be discontinued 7-10 days before the procedure unless the patient is at high thrombotic risk 1
Risk Stratification
High Thrombotic Risk Patients (consider bridging or continuation)
- Mechanical heart valves, especially in mitral position 1
- Recent venous thromboembolism (within 3 months) 1
- Drug-eluting coronary stents within 12 months 1
- Bare metal coronary stents within 1 month 1
- Atrial fibrillation with mitral stenosis 1
High Bleeding Risk Procedures
- Interventional spine procedures where compression cannot be performed 1
- Multiple needle attempts 3
- Use of large bore needles 3
- Cervical spine procedures 3
Post-Procedure Management
- Resume anticoagulant therapy up to 48 hours after the procedure depending on bleeding and thrombotic risks 1
- For warfarin, resume the evening of the procedure if hemostasis is adequate 1
- For patients requiring bridging therapy, restart LMWH 24 hours after the procedure if hemostasis is adequate 1
Important Considerations
- The risk of serious bleeding complications from steroid injections while on anticoagulants is relatively low (1.5% for joint injections) 4, but spinal injections carry higher risk due to the potential for epidural hematoma
- The decision to discontinue therapy must balance bleeding risk against thrombotic risk
- For minor procedures with low bleeding risk, anticoagulants may not need to be discontinued 1
- Recent evidence suggests that hand and wrist injections can be safely performed without discontinuing anticoagulants, with only 1.6% complication rate 5, but this cannot be directly extrapolated to spinal injections
Common Pitfalls to Avoid
- Failing to check INR before the procedure in patients on warfarin
- Not providing adequate bridging therapy for high thrombotic risk patients
- Discontinuing anticoagulants for too long, increasing thrombotic risk
- Restarting anticoagulants too soon after the procedure, increasing bleeding risk
- Not consulting with the prescribing physician (cardiologist, neurologist) before stopping antiplatelet therapy in high-risk patients
By following these guidelines, the risk of bleeding complications from steroid injections in the back can be minimized while managing the risk of thrombotic events in patients requiring anticoagulation.