Do I need to hold aspirin (acetylsalicylic acid) and Plavix (clopidogrel) before undergoing acupuncture?

Antiplatelet Management for Acupuncture

You do not need to hold aspirin or Plavix (clopidogrel) for acupuncture in most clinical scenarios, as the bleeding risk from acupuncture is extremely low and does not justify the thrombotic risk of discontinuation. 1

Evidence-Based Risk Assessment

Bleeding Risk from Acupuncture

• The incidence of minor bleeding (skin bleeding or contusion) after acupuncture is only 8.31 per 10,000 needles, and major bleeding (visceral bleeding or ruptured blood vessels requiring transfusion) occurs at just 4.26 per 100,000 needles. 1

• Anticoagulants like warfarin, direct oral anticoagulants, and heparin significantly increase bleeding risk after acupuncture, but antiplatelet drugs (including aspirin and clopidogrel) are NOT significantly associated with post-acupuncture bleeding. 1

• Serious acupuncture-related adverse events are rare, occurring at approximately 0.04-0.08 per 10,000 treatments, with the most common minor adverse events being bruising, hematoma, or bleeding at the needling site. 2

Thrombotic Risk of Discontinuation

Aspirin Discontinuation Risks

• Discontinuation of aspirin for secondary prevention is associated with a nearly sevenfold increase in risk for death or acute cardiovascular events. 3

• All-cause mortality is 10 times lower in patients who continue aspirin compared to those who discontinue it in bleeding scenarios. 3

Clopidogrel Discontinuation Risks

• For patients on dual antiplatelet therapy (DAPT), simultaneous discontinuation of both antiplatelet agents carries high risk of stent thrombosis, which can occur in as little as 7 days when both drugs are withheld. 3, 4

• The FDA drug label for clopidogrel explicitly warns that people who stop taking clopidogrel too soon have a higher risk of having a heart attack or dying. 5

• Clopidogrel inhibits platelet aggregation for the lifetime of the platelet (7 to 10 days), and discontinuation increases the risk of cardiovascular events. 5

Clinical Decision Algorithm

For Patients on Aspirin Alone

• Continue aspirin without interruption for acupuncture, as the research shows antiplatelet drugs are not significantly associated with post-acupuncture bleeding. 1

• The thrombotic risk of discontinuation far outweighs the minimal bleeding risk from acupuncture. 3

For Patients on Clopidogrel (Plavix) Alone

• Continue clopidogrel without interruption for acupuncture, as antiplatelet drugs are not significantly associated with post-acupuncture bleeding. 1

• The FDA label warns against stopping clopidogrel without consulting the prescribing physician due to increased cardiovascular risk. 5

For Patients on Dual Antiplatelet Therapy (Aspirin + Clopidogrel)

• Continue both medications without interruption for acupuncture, as the research demonstrates antiplatelet drugs do not significantly increase post-acupuncture bleeding risk. 1

• Never discontinue both agents simultaneously, as stent thrombosis can occur within 7 days. 3, 4

Risk Factors Requiring Extra Caution

The following patient factors increase bleeding risk after acupuncture and warrant heightened vigilance (but still do not require discontinuation of antiplatelet therapy): 1

• Liver cirrhosis
• Diabetes mellitus
• Coagulation defects
• Concomitant anticoagulant use (warfarin, DOACs, heparin)

Acupuncturist Safety Precautions

To minimize bleeding risk during acupuncture in patients on antiplatelet therapy, practitioners should: 2

• Carefully select needling areas and avoid deep needle penetration
• Use correct acupoint selection and proper needle manipulation
• Maintain strict hygiene with adequate skin disinfection
• Avoid aggressive manipulation and repeated reheating of needles
• Be aware of anatomic contraindications

Common Pitfalls to Avoid

• Do not routinely discontinue aspirin or clopidogrel for acupuncture based on theoretical bleeding concerns, as the actual bleeding risk is minimal and the thrombotic risk of discontinuation is substantial. 1, 3

• Do not confuse the management of antiplatelet drugs with anticoagulants (warfarin, DOACs, heparin), which DO significantly increase bleeding risk and may require different management. 1

• Do not stop clopidogrel without consulting the prescribing cardiologist, especially in patients with recent coronary stents (within 12 months). 5