From the Guidelines
Therapeutic phlebotomy is still necessary for someone with high hemoglobin, even if they are on blood thinners, if their hemoglobin level is greater than 20 g per dL and hematocrit is greater than 65%, associated with symptoms of hyperviscosity. Blood thinners like warfarin, apixaban, or heparin prevent clotting but don't reduce the actual number of red blood cells or hemoglobin levels [ 1 ]. The decision to perform therapeutic phlebotomy should be based on the underlying cause of high hemoglobin, target hemoglobin levels, and the patient's symptoms.
Key Considerations
- The patient's symptoms, such as headache, increasing fatigue, or other symptoms of hyperviscosity, should be taken into account when deciding on therapeutic phlebotomy [ 1 ].
- The frequency of phlebotomy sessions should be determined by a hematologist based on serial hemoglobin measurements, with the goal of maintaining appropriate levels while minimizing risks associated with both conditions [ 1 ].
- During phlebotomy while on anticoagulants, extra care should be taken to monitor for bleeding at the venipuncture site, and pressure should be applied longer after the procedure.
Treatment Approach
- Therapeutic phlebotomy is usually unnecessary unless the hemoglobin is more than 20 g/dL and the hematocrit is greater than 65% with associated symptoms of hyperviscosity and no evidence of dehydration [ 1 ].
- The purpose of the phlebotomy is to relieve hyperviscosity symptoms and occasionally, before elective operation, to improve coagulation.
- Repetitive phlebotomies deplete iron stores and may result in production of iron-deficient red blood cells, which is undesirable due to the reduced oxygen-carrying capacity and deformability of red blood cells [ 1 ].
From the Research
Therapeutic Phlebotomy and Blood Thinners
- The provided studies do not directly address the need for therapeutic phlebotomy in individuals with high hemoglobin levels who are already on blood thinners 2, 3, 4, 5, 6.
- However, the studies discuss the management of bleeding in patients taking anticoagulants, including the use of reversal agents and blood products 3, 4, 5, 6.
- The studies also highlight the importance of careful management of anticoagulation therapy to minimize the risk of bleeding and thrombosis 2, 5.
- In patients with high hemoglobin levels, therapeutic phlebotomy may be considered to reduce the risk of thrombosis, but the decision to perform phlebotomy should be made on a case-by-case basis, taking into account the individual's overall clinical condition and the potential risks and benefits of the procedure.
- The use of blood thinners, such as anticoagulants, may affect the management of therapeutic phlebotomy, and clinicians should be aware of the potential interactions between these medications and the phlebotomy procedure 3, 4, 5, 6.