Is it safe to administer a knee cortisone (corticosteroid) injection to a patient on active Deep Vein Thrombosis (DVT) treatment?

Safety of Knee Cortisone Injection in Patients on Active DVT Treatment

Administering a knee cortisone injection to a patient on active DVT treatment is generally safe, provided the patient is adequately anticoagulated and there are no local contraindications to the injection.

Rationale for Safety

The primary concern with performing procedures in anticoagulated patients is bleeding risk. However, knee joint injections are considered low-risk procedures from a bleeding perspective for the following reasons:

• Knee joint injections are superficial procedures
• The procedure involves minimal tissue trauma
• The joint space is easily accessible
• Direct compression can be applied if bleeding occurs

Considerations Before Proceeding

Anticoagulation Status

• Ensure the patient is on stable anticoagulation therapy
• For patients on VKA (warfarin), verify INR is in therapeutic range (2.0-3.0) 1
• For patients on DOACs (apixaban, dabigatran, edoxaban, rivaroxaban), confirm appropriate dosing and adherence 1

Local Factors

• Absence of cellulitis or infection over the injection site
• No evidence of joint infection
• No severe soft tissue swelling that would obscure landmarks

Procedure Recommendations

1. Timing of injection:

   • For patients on once-daily DOACs, consider performing the injection just before the next scheduled dose
   • For patients on warfarin, proceed if INR is within therapeutic range (2.0-3.0)

2. Technique modifications:

   • Use smaller gauge needle (25G or 27G if possible)
   • Apply firm pressure for 5 minutes post-injection
   • Consider using ultrasound guidance to improve accuracy and reduce trauma
   • Minimize needle passes/repositioning

3. Post-procedure care:

   • Monitor for excessive bleeding or hemarthrosis for 10-15 minutes
   • Instruct patient to limit activity of the injected joint for 24-48 hours
   • Advise patient to report unusual swelling, pain, or bruising

Special Considerations

DVT Treatment Duration

The duration of anticoagulation for DVT varies based on several factors 1:

• Provoked DVT: minimum 3 months
• Unprovoked DVT: 3-6 months or longer
• Cancer-associated DVT: extended anticoagulation while cancer is active
• Recurrent DVT: extended or indefinite anticoagulation

Choice of Anticoagulant

Current guidelines recommend 1:

• DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) over VKA for most patients
• For cancer-associated thrombosis, oral Xa inhibitors (apixaban, edoxaban, rivaroxaban) over LMWH

Potential Risks and Precautions

1. Bleeding risk:

   • Minor bleeding at injection site is possible but usually self-limiting
   • Hemarthrosis is rare but possible

2. Infection risk:

   • Standard sterile technique should be employed
   • No evidence of increased infection risk in anticoagulated patients

3. DVT propagation:

   • No evidence suggests that joint injections increase risk of DVT propagation or embolization
   • Continued anticoagulation provides protection

Conclusion

Knee cortisone injections can be safely performed in patients on active DVT treatment with appropriate precautions. The benefits of pain relief and improved function from the injection typically outweigh the minimal bleeding risks when proper technique is used and the patient is on stable anticoagulation.