Anticoagulation Management for SI Joint Injection in Atrial Fibrillation
Do not hold Eliquis (apixaban) for a sacroiliac joint cortisone injection. This is a low-risk, minor procedure that does not require interruption of anticoagulation.
Guideline-Based Recommendations
Joint injections are classified as minimal bleeding risk procedures that do not require anticoagulation modification. 1 The most recent consensus from major cardiology societies explicitly states that anticoagulation should not be interrupted for minor procedures with minimal bleeding risk. 1
Supporting Evidence from Major Guidelines
The 2024 ESC Guidelines recommend uninterrupted oral anticoagulation for procedures, emphasizing that unnecessary interruption increases thromboembolic risk. 2
The 2018 CHEST Guidelines specifically address perioperative management and support continuing anticoagulation for low-risk procedures. 2
The 2019 AHA/ACC/HRS Focused Update reinforces that decisions about anticoagulation interruption should be based on both thromboembolic risk profile (like CHA₂DS₂-VASc score) and bleeding risk of the specific procedure. 2
Key Clinical Considerations
Why Continuation is Preferred
Unnecessary interruption of anticoagulation exposes your patient to increased stroke risk that outweighs the minimal bleeding risk from a joint injection. 1 For a 76-year-old with atrial fibrillation, the thromboembolic risk during even brief anticoagulation interruption is substantial.
Pharmacokinetic Context
While older guidelines discuss holding direct oral anticoagulants for 1-2 days before procedures requiring complete hemostasis (such as spinal procedures or major surgery), 2 an SI joint injection does not fall into this high-risk category. The distinction is critical: spinal/epidural procedures requiring complete hemostasis need 48+ hours of discontinuation, but superficial joint injections do not. 2
Common Pitfalls to Avoid
Do not confuse SI joint injections with neuraxial procedures. While epidural or spinal anesthesia requires anticoagulation interruption due to catastrophic bleeding risk, peripheral joint injections carry minimal risk. 1
Do not automatically hold anticoagulation without assessing procedure-specific bleeding risk. This outdated practice increases stroke risk unnecessarily. 1
Ensure the proceduralist is comfortable performing the injection on anticoagulation. If they insist on holding Eliquis, this represents a knowledge gap rather than a medical necessity, and education or consultation may be warranted. 1