From the Guidelines
Hyaluronic acid knee injections can generally be safely administered to patients on chronic anticoagulation therapy, though some precautions should be taken. Patients should continue their anticoagulation medication as prescribed without interruption, as the risk of thromboembolism from discontinuation typically outweighs the small bleeding risk from the injection 1. When performing the injection, use a smaller gauge needle (25-27G) and apply firm pressure to the injection site for 5-10 minutes afterward to minimize bleeding risk. Schedule the injection when the anticoagulant effect is at its lowest point - for warfarin patients, this means ensuring their INR is within therapeutic range (ideally below 3.0), and for direct oral anticoagulants (DOACs) like apixaban or rivaroxaban, consider timing the injection before the next scheduled dose. Following the procedure, patients should be monitored for 15-30 minutes for any signs of hemarthrosis (joint bleeding) and instructed to limit strenuous activity involving the knee for 24-48 hours. The safety profile is favorable because knee injections avoid vascular structures when performed correctly, and hyaluronic acid itself has no anticoagulant properties that would compound bleeding risk. If significant joint swelling, pain, or warmth develops after injection, patients should seek medical attention promptly.
Some key considerations for patients on chronic anticoagulation therapy include:
- The risk of thromboembolism from discontinuation of anticoagulation therapy typically outweighs the small bleeding risk from the injection 1
- The use of heparin bridging may be considered for patients at high risk for thromboembolism who require interruption of VKA therapy for an elective surgery or procedure 1
- The safety profile of hyaluronic acid knee injections is favorable, with no anticoagulant properties that would compound bleeding risk
- Patients should be monitored for signs of hemarthrosis and instructed to limit strenuous activity involving the knee for 24-48 hours after the procedure
It's also important to note that the evidence for the use of hyaluronic acid knee injections in patients with knee osteoarthritis is not consistently supported, and the American Academy of Orthopaedic Surgeons recommends against the routine use of hyaluronic acid in patients with knee osteoarthritis 1. However, the potential benefits of hyaluronic acid knee injections for patients on chronic anticoagulation therapy should be weighed against the potential risks, and the decision to use this treatment should be made on a case-by-case basis.
From the Research
Hyaluronic Acid Knee Injections for Patients on Chronic Anticoagulation
- The use of hyaluronic acid knee injections for patients on chronic anticoagulation is a topic of interest, particularly in relation to the risk of bleeding associated with anticoagulant therapy 2, 3, 4, 5.
- Studies have shown that the risk of bleeding varies among different anticoagulant options, with apixaban and dabigatran generally associated with a lower risk of bleeding compared to warfarin and rivaroxaban 3, 4, 5.
- In the context of knee injections, a study found that intra-articular injections of hyaluronic acid induced positive clinical effects in knees of patients affected by haemophilic arthropathy, with no complications reported 6.
- However, the specific risk of bleeding associated with hyaluronic acid knee injections in patients on chronic anticoagulation is not well-established, and further research is needed to fully understand this relationship.
- It is essential to consider the pharmacokinetic properties of the anticoagulant, the bleeding risk of the procedure, and patient renal function when determining the safety of hyaluronic acid knee injections in patients on chronic anticoagulation 2.
- The available evidence suggests that apixaban and dabigatran may be associated with a lower risk of bleeding compared to warfarin and rivaroxaban, which could inform the choice of anticoagulant in patients undergoing hyaluronic acid knee injections 3, 4, 5.