Is there a risk of bleeding with intravenous (IV) injections in patients on anticoagulant therapy?

From the Guidelines

Yes, there is an increased risk of bleeding with intravenous injections in patients on anticoagulant therapy, particularly for those with excessive anticoagulation (INR ≥5) or certain risk factors such as atrial fibrillation, previous thromboembolism, or mechanical heart valves. Patients taking medications such as warfarin, heparin, low molecular weight heparins (like enoxaparin), direct oral anticoagulants (DOACs) including apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), or edoxaban (Savaysa) should inform healthcare providers before receiving IV injections 1. The risk varies depending on the specific anticoagulant, dosage, and the patient's individual factors, such as the presence of risk factors for thromboembolism, including atrial fibrillation, previous thromboembolism, hypercoagulable conditions, older-generation thrombogenic valves, mechanical tricuspid valves, or more than one mechanical valve 1.

Key Considerations

• Healthcare providers may need to temporarily adjust or hold anticoagulant therapy before certain procedures, monitor coagulation parameters like INR for warfarin users, or time procedures based on the last dose of medication 1.
• The bleeding risk occurs because anticoagulants interfere with the body's normal clotting mechanisms, which are essential for stopping bleeding after needle insertion.
• While minor IV procedures like routine blood draws generally carry minimal risk, larger-bore needles or central line placements pose greater concerns.
• Pressure should be applied to injection sites for longer periods (typically 3-5 minutes rather than the standard 1-2 minutes) to ensure proper clotting and prevent hematoma formation.

Management Strategies

• For patients with excessive anticoagulation (INR ≥5), withholding warfarin and monitoring the level of anticoagulation with serial INR determinations may be sufficient 1.
• In patients with an INR >10 who are not bleeding, administering 1 mg to 2.5 mg of oral vitamin K1 (phytonadione) in addition to holding VKA therapy may be necessary 1.
• In emergency situations, such as uncontrollable bleeding, administration of fresh frozen plasma or prothrombin complex concentrate is reasonable 1.

From the FDA Drug Label

XARELTO can cause bleeding which can be serious and may lead to death. People who take a blood thinner medicine (anticoagulant) like XARELTO, and have medicine injected into their spinal and epidural area, or have a spinal puncture have a risk of forming a blood clot that can cause long-term or permanent loss of the ability to move (paralysis) Spinal or epidural blood clots (hematoma) Your risk of developing a spinal or epidural blood clot is higher if: a thin tube called an epidural catheter is placed in your back to give you certain medicine you take NSAIDs or a medicine to prevent blood from clotting you have a history of difficult or repeated epidural or spinal punctures you have a history of problems with your spine or have had surgery on your spine

The risk of bleeding with intravenous (IV) injections in patients on anticoagulant therapy is present, particularly with spinal or epidural injections. Patients on anticoagulant therapy, such as those taking rivaroxaban or warfarin, have an increased risk of bleeding and hematoma formation, especially with spinal or epidural procedures. Key factors that increase this risk include:

• Use of NSAIDs or other anticoagulant medications
• History of difficult or repeated epidural or spinal punctures
• History of spinal problems or surgery It is essential to carefully weigh the benefits and risks of anticoagulant therapy and to closely monitor patients for signs of bleeding or hematoma formation, especially after IV injections or spinal/epidural procedures 2.

From the Research

Risk of Bleeding with IV Injections in Patients on Anticoagulant Therapy

• The risk of bleeding is a concern for patients on anticoagulant therapy, including those receiving intravenous (IV) injections 3, 4, 5.
• Studies have shown that the risk of bleeding is higher in patients with certain risk factors, such as increasing age, history of bleeding, and specific comorbidities 3.
• The management of anticoagulant therapy in patients undergoing invasive procedures, including IV injections, requires careful evaluation of the risk of thrombosis and bleeding 3, 6.
• Reversal of anticoagulation may be necessary in cases of bleeding, and specific antidotes are available for certain anticoagulants, such as warfarin and dabigatran 4, 5.

Management of Anticoagulant Therapy

• The decision to continue or discontinue anticoagulant therapy in patients undergoing IV injections should be based on the individual patient's risk factors and the type of anticoagulant being used 6, 7.
• For patients on warfarin, the international normalized ratio (INR) should be monitored and managed to minimize the risk of bleeding 3, 6.
• Newer anticoagulants, such as direct oral anticoagulants (DOACs), may have a lower risk of bleeding compared to traditional anticoagulants, but more research is needed to fully understand their safety profile 7.

Specific Anticoagulants and Bleeding Risk

• Warfarin: Reversal of anticoagulation can be achieved with vitamin K1 or prothrombin complex concentrates (PCC) 3, 4.
• DOACs: Limited data are available on the risk of bleeding with DOACs, but studies suggest that they may be safe to use in patients undergoing arthrocentesis and joint injections 7.
• Heparin: Reversal of anticoagulation can be achieved with protamine sulfate 4.