Bone Marrow Biopsy in Patients on Dual Antiplatelet Therapy
Bone marrow biopsy can be safely performed in patients on dual antiplatelet therapy (DAPT), but extra precautions should be taken to minimize bleeding risk. 1
Risk Assessment
- Bone marrow biopsy is classified as having low to moderate bleeding risk, with significant hemorrhage occurring in only 0.007-1.1% of cases 1
- The most frequent and serious adverse event associated with bone marrow biopsy is hemorrhage, which can occasionally require blood transfusion 2
- Myeloproliferative disorders and aspirin therapy are the most common risk factors for hemorrhage following bone marrow biopsy 3, 2
Management Recommendations for Patients on DAPT
Aspirin Management
- Continue aspirin therapy during bone marrow biopsy as the risk of thrombotic events from discontinuation outweighs the bleeding risk 4
- Aspirin discontinuation should only be considered for ultra-high risk procedures, which bone marrow biopsy is not typically classified as 4
P2Y12 Inhibitor Management
- For elective bone marrow biopsy, consider withholding P2Y12 receptor inhibitor (clopidogrel, ticagrelor, prasugrel) 5 days before the procedure while continuing aspirin 4
- For urgent bone marrow biopsies where P2Y12 inhibitor cannot be discontinued, proceed with caution and implement additional hemostatic measures 4
- Resume P2Y12 inhibitor once adequate hemostasis has been achieved 4
Special Considerations
- For patients with recent coronary stent placement (within 1 month), defer elective bone marrow biopsy if possible 4
- If bone marrow biopsy cannot be deferred in high thrombotic risk patients (e.g., recent stent placement), consider consultation with a multidisciplinary team including cardiology 4
- Never discontinue both antiplatelet agents simultaneously due to high risk of stent thrombosis 4, 5
Procedural Recommendations
- Use radial approach when possible to minimize bleeding risk 4
- Apply prolonged pressure at the biopsy site (minimum 10 minutes) 1
- Consider using hemostatic agents at the biopsy site 1
- Monitor the patient for at least 1-2 hours post-procedure for signs of bleeding 1, 6
Risk Factors Requiring Additional Caution
- Patients with myeloproliferative disorders have increased bleeding risk with bone marrow biopsy 3, 2
- Thrombocytopenia significantly increases bleeding risk and should be addressed before proceeding 6
- Patients with high responsiveness to antiplatelet therapy may have increased bleeding risk 7
Follow-up Recommendations
- Provide clear instructions to patients about signs of delayed bleeding and when to seek medical attention 1
- For patients in whom P2Y12 inhibitor was withheld, resume as soon as adequate hemostasis is confirmed 4
- Monitor for both bleeding and thrombotic complications in the post-procedure period 6
In summary, while bone marrow biopsy carries a small risk of bleeding in patients on DAPT, the procedure can generally be performed safely with appropriate precautions. The decision should balance the urgency of the diagnostic need against the thrombotic risk of modifying antiplatelet therapy, particularly in patients with recent coronary stents.