Can an elderly patient taking apixaban (Eliquis) receive a knee injection?

Knee Injections in Elderly Patients Taking Apixaban

Elderly patients taking apixaban (Eliquis) can safely receive knee injections, but the procedure should be temporarily delayed with the last dose of apixaban given 24-48 hours before the injection and resumed 24 hours after the procedure to minimize bleeding risk.

Understanding the Risk

When considering knee injections in patients on direct oral anticoagulants (DOACs) like apixaban, the primary concern is the risk of bleeding complications. The decision requires balancing:

1. The thrombotic risk of temporarily stopping anticoagulation
2. The bleeding risk of performing the injection while anticoagulated

Recommended Approach

Timing of Anticoagulation Pause

• For apixaban (standard 5mg BID dosing):
  • Hold apixaban for 24-48 hours before the knee injection 1
  • Resume apixaban approximately 24 hours after the procedure, once adequate hemostasis is confirmed 2

Procedural Considerations

• Intra-articular corticosteroid injections are effective for knee osteoarthritis pain management and can be safely performed with proper timing of anticoagulation 1
• Use a smaller gauge needle (21-23G) to minimize trauma
• Apply pressure after the injection for 3-5 minutes
• Monitor the injection site for any signs of bleeding or hematoma formation

Special Considerations for Elderly Patients

• Elderly patients often have higher bleeding risk due to:

  • Reduced renal clearance of apixaban
  • Concomitant medications that may increase bleeding risk
  • Fragile vasculature
  • Comorbidities

• For patients ≥80 years or with renal impairment (CrCl 30-50 mL/min), consider extending the pre-procedure hold time to 48 hours if they are on the standard 5mg BID dose 3

Evidence-Based Recommendations

The 2023 World Society of Emergency Surgery guidelines recommend assessing DOAC levels before procedures with bleeding risk, though this may not be available in all settings 1. For non-emergency procedures like knee injections, a planned temporary discontinuation is appropriate.

Intra-articular corticosteroid injections are recommended by the American College of Rheumatology as an effective treatment for knee osteoarthritis 1, and the American Geriatrics Society recognizes them as beneficial for pain management in elderly patients 1.

Risk Mitigation Strategies

• Assess thrombotic risk: For patients with very high thrombotic risk (recent stroke, mechanical heart valve), consult with the prescribing physician before stopping apixaban
• Document recent apixaban dosing: Confirm when the last dose was taken
• Consider renal function: Patients with impaired renal function may have prolonged anticoagulant effect
• Post-procedure monitoring: Observe the patient for 15-30 minutes after the procedure

Common Pitfalls to Avoid

1. Failure to coordinate timing: Not planning the procedure around anticoagulation schedule
2. Inadequate communication: Not informing patients about when to stop and restart their medication
3. Overlooking drug interactions: Not considering other medications that may increase bleeding risk (NSAIDs, aspirin)
4. Ignoring renal function: Not adjusting timing based on the patient's kidney function
5. Missing signs of bleeding: Not providing clear instructions about what symptoms to watch for after the procedure

By following these guidelines, knee injections can be safely performed in elderly patients taking apixaban with minimal risk of bleeding complications while maintaining appropriate thrombotic protection.