Steroid Injections in Patients on Anticoagulation
Patients taking anticoagulants can safely receive steroid injections, particularly via caudal or peripheral routes, without discontinuing their blood thinners, as the risk of hemorrhagic complications is extremely low (0.6-1.6%) and substantially lower than the thromboembolic risk of stopping anticoagulation. 1, 2
Evidence-Based Safety Profile
Hemorrhagic Complication Rates
Hand and wrist corticosteroid injections show minimal bleeding risk even in anticoagulated patients, with only 1.6% complications in patients on blood thinners versus 0.6% in those not anticoagulated—a clinically insignificant difference. 1
Epidural steroid injections in 1,214 procedures demonstrated zero spinal hematomas (major hemorrhagic complications) in patients taking NSAIDs and aspirin-like antiplatelet medications, with only 5.2% experiencing minor bleeding during needle placement that did not require intervention. 3
Caudal epidural steroid injections performed in 392 patients remaining on antithrombotics showed zero reported complications regardless of the specific anticoagulant used or underlying medical condition. 2
Critical Risk-Benefit Analysis
The FDA explicitly warns that combining blood thinners with steroids increases stomach bleeding risk, which is a separate concern from procedural bleeding. 4 However, this gastrointestinal risk relates to oral steroid use, not injection procedures.
Discontinuing anticoagulation poses catastrophic thromboembolic risks (stroke, myocardial infarction, pulmonary embolism) that far exceed the minimal bleeding risk from steroid injections. 2 Patients on anticoagulants typically have serious conditions like prosthetic heart valves or deep vein thrombosis where withholding anticoagulation could be disastrous. 5
Procedure-Specific Recommendations
Safe to Proceed Without Stopping Anticoagulation
Peripheral joint injections (hand, wrist, knee, shoulder): Extremely safe with complication rates under 2% even on blood thinners. 1, 6
Caudal epidural approach: Zero complications reported in large retrospective study of anticoagulated patients. 2
Soft tissue injections (bursa, tendon sheaths): Low-risk procedures that can proceed safely. 6
Higher Risk Procedures Requiring Caution
Transforaminal and interlaminar epidural injections carry theoretical higher risk due to proximity to vascular structures and the epidural venous plexus. 7 One case report documented epidural hematoma despite following anticoagulation guidelines, though this remains exceedingly rare. 7
Clinical Decision Algorithm
Step 1: Assess Anticoagulation Indication
- High-risk conditions (mechanical heart valve, recent stroke/MI, atrial fibrillation with high CHADS2 score): Strongly favor continuing anticoagulation. 5, 2
- Lower-risk conditions (primary prevention): May consider brief interruption for high-risk spinal procedures only.
Step 2: Evaluate Injection Site Risk
- Low-risk sites (peripheral joints, soft tissue, caudal epidural): Proceed without stopping anticoagulation. 1, 2
- Moderate-risk sites (interlaminar epidural): Proceed with caution; consider alternative approaches. 3
- Higher-risk sites (transforaminal epidural in anticoagulated patient): Use shared decision-making; consider alternative pain management. 7
Step 3: Technical Modifications
- Use smaller gauge needles when possible to minimize vascular trauma. 3
- Minimize number of needle passes and avoid multiple interspace attempts. 3
- Apply prolonged direct pressure post-injection.
Important Caveats and Pitfalls
Avoid Routine Discontinuation
Do not routinely stop anticoagulation for steroid injections, as this practice is not supported by evidence and exposes patients to unnecessary thromboembolic risk. 2 The catastrophic events from stopping antithrombotics outweigh the minimal bleeding risk from most injection procedures. 2
Monitor for Delayed Complications
While immediate major bleeding is rare, patients should be counseled to report:
- New or progressive neurologic symptoms lasting >24 hours (median duration 3 days in benign cases). 3
- Severe back pain or lower extremity weakness suggesting epidural hematoma. 7
Special Considerations for Specific Anticoagulants
Warfarin patients: If procedure must be delayed, strict adherence to bridging protocols is essential, though even with perfect compliance, rare hematomas can occur. 7
Direct oral anticoagulants (DOACs): Limited specific data, but extrapolation from antiplatelet studies suggests similar safety profile. 1, 3
Gastrointestinal Bleeding Risk
Patients on both oral steroids and anticoagulants face substantially increased GI bleeding risk and should receive proton pump inhibitor prophylaxis. 5, 4 This is distinct from procedural bleeding risk but must be addressed in overall care planning.