- Email: [email protected]
Arthrocentesis and Joint Injection in Patients Receiving Direct Oral Anticoagulants
BRIEF REPORT
Arthrocentesis and Joint Injection in Patients Receiving Direct Oral Anticoagulants Jennifer C. Yui, MD; Carina Preskill, MD; and Laura S. Greenlund, MD, PhD Abstract Anticoagulation is common in patients undergoing arthrocentesis and joint injections. Previous studies have established the safety of continuing anticoagulation with warfarin before joint aspirations/injections with only a small increased risk of bleeding, but no data are available regarding the use of direct oral anticoagulants (DOACs) and joint aspirations/injections. The objective of this study was to determine the rate of bleeding complications associated with arthrocentesis and joint injection in patients receiving DOACs. We performed a retrospective review of adult patients at Mayo Clinic in Rochester, Minnesota, who were being treated with DOACs and underwent outpatient joint aspiration and/or injection between October 1, 2010, and October 31, 2016. In 1050 consecutive procedures, there were no bleeding complications. Arthrocentesis and joint injections in patients receiving DOAC therapy are safe procedures, and there is no need to withhold anticoagulation treatment before the procedure. ª 2017 Mayo Foundation for Medical Education and Research
J
oint aspirations and injections are commonly performed outpatient procedures that are generally safe and well tolerated but associated with a risk of bleeding, particularly in patients receiving pharmacological anticoagulation. Anticoagulation with warfarin is common among patients undergoing arthrocentesis and is associated with a small increased risk of bleeding complications when the international normalized ratio (INR) is greater than 2.1 Since 2010, direct oral anticoagulant (DOAC) use has increased for stroke prevention in the setting of nonvalvular atrial fibrillation and for treatment and prevention of venous thromboembolism (VTE). The DOACs include direct thrombin inhibitors, of which dabigatran is the only currently available agent, and direct factor Xa inhibitors including rivaroxaban, apixaban, and edoxaban. Since the US Food and Drug Administration (FDA) approval of dabigatran in October 2010, DOACs have been prescribed with increasing frequency because they do not require regular laboratory monitoring and are associated with lower risks of major bleeding compared with warfarin.2-7 Studies report that for patients receiving warfarin who have an INR of 2.0 to 3.0, the bleeding risk associated with arthrocentesis is
n
Mayo Clin Proc. 2017;92(8):1223-1226
low, quantitated at 0.2% or lower,1,8-11 although this risk is likely increased in patients with higher INRs.12 It has been recommended that warfarin be continued to maintain a therapeutic INR in patients undergoing joint injections/aspirations because these procedures are considered to have a relatively low risk for bleeding complications.13 However, the risk of bleeding associated with arthrocentesis and aspirations in patients receiving DOACs has not been reported, and clinical practice varies. Some practitioners may continue anticoagulation, accepting the bleeding risk, whereas others may withhold anticoagulation, which can put patients at risk of thromboembolic events and delay necessary procedures. The aim of this study was to determine the rate of bleeding complications associated with arthrocentesis and joint injection in patients receiving DOACs to inform clinical practice about continuing or withholding DOACs before joint procedures.
For editorial comment, see page 1176 From the Department of Medicine, Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN.
PATIENTS AND METHODS We performed a retrospective medical record review of 1050 arthrocentesis and joint injection procedures performed in consecutive adult patients (aged 18 years) at a single institution (Mayo Clinic in Rochester, Minnesota) between October 1, 2010, and October
Mayo Clin Proc. n August 2017;92(8):1223-1226 n http://dx.doi.org/10.1016/j.mayocp.2017.04.007 www.mayoclinicproceedings.org n ª 2017 Mayo Foundation for Medical Education and Research
1223
MAYO CLINIC PROCEEDINGS
31, 2016. The authors served as 3 independent medical record abstractors, performing data collection using a standardized form. Queries were performed using Current Procedural Terminology codes 20600, 20604, 20605, 20606, 20610, and 20611. Only procedures performed in the outpatient setting, including the emergency department, were included. All patients were receiving DOACs, as determined by their active outpatient medication lists at the time of the procedure. Clinical notes and procedural notes were reviewed, and patients were excluded if DOAC therapy was withheld before the procedure. No preexisting protocol was in place regarding the management of anticoagulation before arthrocentesis and injection. Procedure techniques, including use of ultrasonography, were selected according to the preference of the ordering and performing physicians. Data collected included demographic characteristics, procedural details, laboratory data, medication review, and bleeding complications. Laboratory values were included if they were performed within 90 days before the procedure. Bleeding complications were defined as clinically important bleeding leading to outpatient clinic or emergency department visits or hospitalization within the Mayo Clinic health care system within 14 days after the procedure. Patient place of residence was recorded on the basis of the address listed within the patient record. Residence was defined as international if outside the United States and local within Olmsted County or one of the surrounding counties (Dodge, Fillmore, Goodhue, Mower, Wabasha, and Winona counties). Descriptive statistics were used to characterize the overall sample.
RESULTS During the study period, 1050 procedures were performed in 483 unique patients. The baseline characteristics of the patients for each unique procedure are presented in the Table. The median age was 75 years, and 247 of the 483 patients (51.1%) were female. The median body mass index was 30.5; 197
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TABLE. Demographic and Clinical Characteristics of 483 Patients Receiving DOACs Who Underwent 1050 Arthrocentesis and Joint Injection Proceduresa,b,c Variable Age (y) Female BMI (n¼1035) Injections into bursa Ultrasound guidance Usage of aspirin Usage of clopidogrel Hemoglobin (g/dL) (n¼865) Platelet count (109/L) (n¼867) INR (n¼303) Creatinine (mg/dL) (n¼886) AST (U/L) (n¼425) ALT (U/L) (n¼224)
Value 75 247 30.5 217 506 226 10 13.1 217 1.2 1.0 24 20
(20-96) (51.1) (14.6-64.0) (20.7) (48.2) (21.5) (1.0) (7.3-18.9) (91-713) (0.5-3.6) (0.5-3.6) (9-256) (7-224)
ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; BMI ¼ body mass index; DOAC ¼ direct oral anticoagulant; INR ¼ international normalized ratio. b Data are presented as No. (percentage) of procedures or mean (range). c SI conversion factors: To convert hemoglobin values to g/L, multiply by 10.0; to convert creatinine values to mmol/L, multiply by 88.4; to convert AST and ALT values to mkat/L, multiply by 0.0167. a
of the 483 patients (40.8%) were local, and 36 (7.4%) were international. Of the 1050 procedures, 226 (21.5%) were performed in patients receiving a DOAC and aspirin, and 10 (1.0%) were performed in patients receiving a DOAC and clopidogrel. Of note, 68 of the 1050 procedures (6.5%) were performed in patients with thrombocytopenia (platelet count <150 109/L), and 34 procedures (3.2%) were performed in patients with an INR greater than 1.5. There were 49 procedures (4.7%) performed in patients with a creatinine concentration greater than 1.5 mg/dL (to convert to mmol/L, multiply by 88.4), and 4 (0.4%) with an aspartate aminotransferase or alanine aminotransferase level more than 3 times the upper limit of normal. Rivaroxaban was the most common DOAC, accounting for 548 of the 1050 procedures (52.2%) (Figure 1). Apixaban and dabigatran accounted for 325 (30.9%) and 177 (16.9%) procedures, respectively. No patients were
August 2017;92(8):1223-1226
n
http://dx.doi.org/10.1016/j.mayocp.2017.04.007 www.mayoclinicproceedings.org
ARTHROCENTESIS AND JOINT INJECTION WITH DOACS
DISCUSSION Previous studies have documented the overall safety of arthrocentesis, including procedures in patients undergoing therapeutic anticoagulation with warfarin.1,8-11 Our study suggests that it is safe to perform joint or bursa injections and arthrocentesis in patients receiving DOACs. Our study population included patients with renal dysfunction, hepatic dysfunction, and concomitant use of aspirin or clopidogrel. Procedures in our study were performed in both primary care and subspecialty Mayo Clin Proc. n August 2017;92(8):1223-1226 www.mayoclinicproceedings.org
n
400
Dabigatran
Rivaroxaban
Apixaban
No. of procedures
350 300 250 200 150 100 50 16 01
5-
10
/2 0
15 /2 11
01
4-
10
/2 0
14 /2 11
01
3-
10
/2 0
13 /2 11
11
/2
01
2-
10
/2 0
12 /2 0 10 101 /2
11
/2
01
0-
10
/2 0
11
0
11
using edoxaban at the time of procedure. The most common indications for anticoagulation were atrial fibrillation in 356 of the 483 patients (73.7%) and VTE in 114 (23.6%). Other indications included hypercoagulable states, VTE prophylaxis in postsurgical patients, and history of cerebrovascular accident. Figure 2 summarizes the distribution of joints injected/aspirated. The most common joint was the knee in 442 of the 1050 procedures (42.1%), followed by the shoulder in 142 (13.5%), hip bursa in 107 (10.2%), hand/wrist in 103 (9.8%), and hip joint in 100 (9.5%). Of the procedures performed, 833 (79.3%) were intra-articular and 217 (20.7%) involved the bursa. The setting for the procedures varied, with 206 (19.6%) performed in a primary care setting and the remainder in subspecialty areas including orthopedic surgery, rheumatology, pain medicine, and physical medicine and rehabilitation departments. Ultrasound guidance was utilized in 506 procedures (48.2%), with an additional 36 (3.4%) performed with direct fluoroscopic visualization. There were no bleeding complications in any of the 1050 procedures. Follow-up ranged from 0 to 1307 days after the procedure, and only 5 procedures (0.5%) did not have any follow-up within our health care system as of March 1, 2017. Overall, patients had followup appointments within 30 days of the procedure after 913 procedures (87.0%), with a median time to follow-up of 5 days. These findings were also true of international and nonlocal patients, who had shorter median follow-up times reflecting typical scheduling of multiple appointments within a short period for nonlocal patients.
Procedure date
FIGURE 1. Joint aspirations and injections performed at Mayo Clinic in Rochester, Minnesota, in patients receiving direct oral anticoagulant therapy. Note increase in the number of procedures and change in prescribing trends over time.
settings and included both landmark-guided and ultrasound-guided procedures. Our data also reveal general trends in prescribing practices with regard to DOACs. Because dabigatran was the first FDAapproved DOAC, it comprised the majority of DOAC prescriptions in 2011 and 2012. However, after the FDA approval of rivaroxaban in 2011, we observed a rapid increase in the proportion of study patients receiving
Foot/ankle Hand/wrist Hip Hip bursa Knee Knee bursa Miscellaneous Shoulder Shoulder bursa Spine/SI 0
5
10
15
20 25 30 Procedures (%)
35
40
45
FIGURE 2. Distribution of joints apirated/injected at Mayo Clinic in Rochester, Minnesota, in patients receiving direct oral anticoagulant therapy. The knee was the most frequent site of aspiration or injection, followed by the shoulder, hip bursa, and hand/wrist. SI ¼ sacroiliac joint.
http://dx.doi.org/10.1016/j.mayocp.2017.04.007
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this DOAC, likely reflecting the convenience of rivaroxaban relative to dabigatran, which requires a 5-day overlap with intravenous heparin at the time of initiation for acute VTE.14 Patients receiving apixaban before its FDA approval in 2014 likely represent clinical trial participants. Since 2014, there was a shift toward apixaban in our study patients, which may be related to the lower rate of bleeding complications with apixaban.2,15 Our study has several limitations. First, our data are retrospective and derived from a single large medical center database. If patients continued DOAC medications preprocedurally but this use was not documented in the medication list or clinical/procedural notes, these patients may not have been captured within the study population. Assessment of bleeding complications was limited to follow-up encounters occurring within our center’s health care system and would not capture events for which patients sought care at other facilities. However, given the median follow-up of 5 days and that 87.0% of our patients had follow-up encounters within 30 days, it is unlikely that a substantial number of events were not captured. Further, we did not include a control population of either patients taking warfarin or not receiving anticoagulants. Given that general bleeding rates have been consistent in the literature,8-12 it is unlikely that rates would be different in our center because of any unique population factors. This study population did include patients with renal and hepatic failure and those receiving antiplatelet therapy, but there were relatively few such patients, and further study may be necessary to determine the safety of procedures in these populations specifically.
CONCLUSION Overall, the data from this study indicate that patients receiving DOACs at the time of joint or bursa aspirations and injections do not have an increased risk of bleeding complications. Direct oral anticoagulants can safely be continued before these procedures.
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Abbreviations and Acronyms: DOAC = direct oral anticoagulant; FDA = Food and Drug Administration; INR = international normalized ratio; VTE = venous thromboembolism Correspondence: Address to Laura S. Greenlund, MD, PhD, Department of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55902 (greenlund.laura@ mayo.edu).
REFERENCES 1. Ahmed I, Gertner E. Safety of arthrocentesis and joint injection in patients receiving anticoagulation at therapeutic levels. Am J Med. 2012;125(3):265-269. 2. Agnelli G, Buller HR, Cohen A, et al; AMPLIFY Investigators. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013;369(9):799-808. 3. Connolly SJ, Ezekowitz MD, Yusuf S, et al; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation [published correction appears in N Engl J Med. 2010;363(19):1877]. N Engl J Med. 2009;361(12): 1139-1151. 4. Hokusai VTE Investigators. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism [published correction appears in N Engl J Med. 2014;370(4):390]. N Engl J Med. 2013;369(15):1406-1415. 5. EINSTEIN-PE Investigators. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012; 366(14):1287-1297. 6. Robertson L, Kesteven P, McCaslin JE. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis. Cochrane Database Syst Rev. 2015;(6): CD010956. 7. Robertson L, Kesteven P, McCaslin JE. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of pulmonary embolism. Cochrane Database Syst Rev. 2015;(12): CD010957. 8. Bashir MA, Ray R, Sarda P, Li S, Corbett S. Determination of a safe INR for joint injections in patients taking warfarin. Ann R Coll Surg Engl. 2015;97(8):589-591. 9. Conway R, O’Shea FD, Cunnane G, Doran MF. Safety of joint and soft tissue injections in patients on warfarin anticoagulation. Clin Rheumatol. 2013;32(12):1811-1814. 10. Guillen Astete C, Boteanu A, Medina Quiñones C, et al. Is it safe to perform joint infiltrations or aspirations in patients anticoagulated with acenocoumarol? Reumatol Clin. 2015; 11(1):9-11. 11. Thumboo J, O’Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum. 1998;41(4):736-739. 12. Salvati G, Punzi L, Pianon M, et al. Frequency of the bleeding risk in patients receiving warfarin submitted to arthrocentesis of the knee [in Italian]. Reumatismo. 2003; 55(3):159-163. 13. Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med. 2013;368(22):2113-2124. 14. Pradaxa [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; 2015. 15. Noseworthy PA, Yao X, Abraham NS, Sangaralingham LR, McBane RD, Shah ND. Direct comparison of dabigatran, rivaroxaban, and apixaban for effectiveness and safety in nonvalvular atrial fibrillation. Chest. 2016;150(6):1302-1312.
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Arthrocentesis and Joint Injection in Patients Receiving Direct Oral Anticoagulants Jennifer C. Yui, MD; Carina Preskill, MD; and Laura S. Greenlund, MD, PhD Abstract Anticoagulation is common in patients undergoing arthrocentesis and joint injections. Previous studies have established the safety of continuing anticoagulation with warfarin before joint aspirations/injections with only a small increased risk of bleeding, but no data are available regarding the use of direct oral anticoagulants (DOACs) and joint aspirations/injections. The objective of this study was to determine the rate of bleeding complications associated with arthrocentesis and joint injection in patients receiving DOACs. We performed a retrospective review of adult patients at Mayo Clinic in Rochester, Minnesota, who were being treated with DOACs and underwent outpatient joint aspiration and/or injection between October 1, 2010, and October 31, 2016. In 1050 consecutive procedures, there were no bleeding complications. Arthrocentesis and joint injections in patients receiving DOAC therapy are safe procedures, and there is no need to withhold anticoagulation treatment before the procedure. ª 2017 Mayo Foundation for Medical Education and Research
J
oint aspirations and injections are commonly performed outpatient procedures that are generally safe and well tolerated but associated with a risk of bleeding, particularly in patients receiving pharmacological anticoagulation. Anticoagulation with warfarin is common among patients undergoing arthrocentesis and is associated with a small increased risk of bleeding complications when the international normalized ratio (INR) is greater than 2.1 Since 2010, direct oral anticoagulant (DOAC) use has increased for stroke prevention in the setting of nonvalvular atrial fibrillation and for treatment and prevention of venous thromboembolism (VTE). The DOACs include direct thrombin inhibitors, of which dabigatran is the only currently available agent, and direct factor Xa inhibitors including rivaroxaban, apixaban, and edoxaban. Since the US Food and Drug Administration (FDA) approval of dabigatran in October 2010, DOACs have been prescribed with increasing frequency because they do not require regular laboratory monitoring and are associated with lower risks of major bleeding compared with warfarin.2-7 Studies report that for patients receiving warfarin who have an INR of 2.0 to 3.0, the bleeding risk associated with arthrocentesis is
n
Mayo Clin Proc. 2017;92(8):1223-1226
low, quantitated at 0.2% or lower,1,8-11 although this risk is likely increased in patients with higher INRs.12 It has been recommended that warfarin be continued to maintain a therapeutic INR in patients undergoing joint injections/aspirations because these procedures are considered to have a relatively low risk for bleeding complications.13 However, the risk of bleeding associated with arthrocentesis and aspirations in patients receiving DOACs has not been reported, and clinical practice varies. Some practitioners may continue anticoagulation, accepting the bleeding risk, whereas others may withhold anticoagulation, which can put patients at risk of thromboembolic events and delay necessary procedures. The aim of this study was to determine the rate of bleeding complications associated with arthrocentesis and joint injection in patients receiving DOACs to inform clinical practice about continuing or withholding DOACs before joint procedures.
For editorial comment, see page 1176 From the Department of Medicine, Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN.
PATIENTS AND METHODS We performed a retrospective medical record review of 1050 arthrocentesis and joint injection procedures performed in consecutive adult patients (aged 18 years) at a single institution (Mayo Clinic in Rochester, Minnesota) between October 1, 2010, and October
Mayo Clin Proc. n August 2017;92(8):1223-1226 n http://dx.doi.org/10.1016/j.mayocp.2017.04.007 www.mayoclinicproceedings.org n ª 2017 Mayo Foundation for Medical Education and Research
1223
MAYO CLINIC PROCEEDINGS
31, 2016. The authors served as 3 independent medical record abstractors, performing data collection using a standardized form. Queries were performed using Current Procedural Terminology codes 20600, 20604, 20605, 20606, 20610, and 20611. Only procedures performed in the outpatient setting, including the emergency department, were included. All patients were receiving DOACs, as determined by their active outpatient medication lists at the time of the procedure. Clinical notes and procedural notes were reviewed, and patients were excluded if DOAC therapy was withheld before the procedure. No preexisting protocol was in place regarding the management of anticoagulation before arthrocentesis and injection. Procedure techniques, including use of ultrasonography, were selected according to the preference of the ordering and performing physicians. Data collected included demographic characteristics, procedural details, laboratory data, medication review, and bleeding complications. Laboratory values were included if they were performed within 90 days before the procedure. Bleeding complications were defined as clinically important bleeding leading to outpatient clinic or emergency department visits or hospitalization within the Mayo Clinic health care system within 14 days after the procedure. Patient place of residence was recorded on the basis of the address listed within the patient record. Residence was defined as international if outside the United States and local within Olmsted County or one of the surrounding counties (Dodge, Fillmore, Goodhue, Mower, Wabasha, and Winona counties). Descriptive statistics were used to characterize the overall sample.
RESULTS During the study period, 1050 procedures were performed in 483 unique patients. The baseline characteristics of the patients for each unique procedure are presented in the Table. The median age was 75 years, and 247 of the 483 patients (51.1%) were female. The median body mass index was 30.5; 197
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n
TABLE. Demographic and Clinical Characteristics of 483 Patients Receiving DOACs Who Underwent 1050 Arthrocentesis and Joint Injection Proceduresa,b,c Variable Age (y) Female BMI (n¼1035) Injections into bursa Ultrasound guidance Usage of aspirin Usage of clopidogrel Hemoglobin (g/dL) (n¼865) Platelet count (109/L) (n¼867) INR (n¼303) Creatinine (mg/dL) (n¼886) AST (U/L) (n¼425) ALT (U/L) (n¼224)
Value 75 247 30.5 217 506 226 10 13.1 217 1.2 1.0 24 20
(20-96) (51.1) (14.6-64.0) (20.7) (48.2) (21.5) (1.0) (7.3-18.9) (91-713) (0.5-3.6) (0.5-3.6) (9-256) (7-224)
ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; BMI ¼ body mass index; DOAC ¼ direct oral anticoagulant; INR ¼ international normalized ratio. b Data are presented as No. (percentage) of procedures or mean (range). c SI conversion factors: To convert hemoglobin values to g/L, multiply by 10.0; to convert creatinine values to mmol/L, multiply by 88.4; to convert AST and ALT values to mkat/L, multiply by 0.0167. a
of the 483 patients (40.8%) were local, and 36 (7.4%) were international. Of the 1050 procedures, 226 (21.5%) were performed in patients receiving a DOAC and aspirin, and 10 (1.0%) were performed in patients receiving a DOAC and clopidogrel. Of note, 68 of the 1050 procedures (6.5%) were performed in patients with thrombocytopenia (platelet count <150 109/L), and 34 procedures (3.2%) were performed in patients with an INR greater than 1.5. There were 49 procedures (4.7%) performed in patients with a creatinine concentration greater than 1.5 mg/dL (to convert to mmol/L, multiply by 88.4), and 4 (0.4%) with an aspartate aminotransferase or alanine aminotransferase level more than 3 times the upper limit of normal. Rivaroxaban was the most common DOAC, accounting for 548 of the 1050 procedures (52.2%) (Figure 1). Apixaban and dabigatran accounted for 325 (30.9%) and 177 (16.9%) procedures, respectively. No patients were
August 2017;92(8):1223-1226
n
http://dx.doi.org/10.1016/j.mayocp.2017.04.007 www.mayoclinicproceedings.org
ARTHROCENTESIS AND JOINT INJECTION WITH DOACS
DISCUSSION Previous studies have documented the overall safety of arthrocentesis, including procedures in patients undergoing therapeutic anticoagulation with warfarin.1,8-11 Our study suggests that it is safe to perform joint or bursa injections and arthrocentesis in patients receiving DOACs. Our study population included patients with renal dysfunction, hepatic dysfunction, and concomitant use of aspirin or clopidogrel. Procedures in our study were performed in both primary care and subspecialty Mayo Clin Proc. n August 2017;92(8):1223-1226 www.mayoclinicproceedings.org
n
400
Dabigatran
Rivaroxaban
Apixaban
No. of procedures
350 300 250 200 150 100 50 16 01
5-
10
/2 0
15 /2 11
01
4-
10
/2 0
14 /2 11
01
3-
10
/2 0
13 /2 11
11
/2
01
2-
10
/2 0
12 /2 0 10 101 /2
11
/2
01
0-
10
/2 0
11
0
11
using edoxaban at the time of procedure. The most common indications for anticoagulation were atrial fibrillation in 356 of the 483 patients (73.7%) and VTE in 114 (23.6%). Other indications included hypercoagulable states, VTE prophylaxis in postsurgical patients, and history of cerebrovascular accident. Figure 2 summarizes the distribution of joints injected/aspirated. The most common joint was the knee in 442 of the 1050 procedures (42.1%), followed by the shoulder in 142 (13.5%), hip bursa in 107 (10.2%), hand/wrist in 103 (9.8%), and hip joint in 100 (9.5%). Of the procedures performed, 833 (79.3%) were intra-articular and 217 (20.7%) involved the bursa. The setting for the procedures varied, with 206 (19.6%) performed in a primary care setting and the remainder in subspecialty areas including orthopedic surgery, rheumatology, pain medicine, and physical medicine and rehabilitation departments. Ultrasound guidance was utilized in 506 procedures (48.2%), with an additional 36 (3.4%) performed with direct fluoroscopic visualization. There were no bleeding complications in any of the 1050 procedures. Follow-up ranged from 0 to 1307 days after the procedure, and only 5 procedures (0.5%) did not have any follow-up within our health care system as of March 1, 2017. Overall, patients had followup appointments within 30 days of the procedure after 913 procedures (87.0%), with a median time to follow-up of 5 days. These findings were also true of international and nonlocal patients, who had shorter median follow-up times reflecting typical scheduling of multiple appointments within a short period for nonlocal patients.
Procedure date
FIGURE 1. Joint aspirations and injections performed at Mayo Clinic in Rochester, Minnesota, in patients receiving direct oral anticoagulant therapy. Note increase in the number of procedures and change in prescribing trends over time.
settings and included both landmark-guided and ultrasound-guided procedures. Our data also reveal general trends in prescribing practices with regard to DOACs. Because dabigatran was the first FDAapproved DOAC, it comprised the majority of DOAC prescriptions in 2011 and 2012. However, after the FDA approval of rivaroxaban in 2011, we observed a rapid increase in the proportion of study patients receiving
Foot/ankle Hand/wrist Hip Hip bursa Knee Knee bursa Miscellaneous Shoulder Shoulder bursa Spine/SI 0
5
10
15
20 25 30 Procedures (%)
35
40
45
FIGURE 2. Distribution of joints apirated/injected at Mayo Clinic in Rochester, Minnesota, in patients receiving direct oral anticoagulant therapy. The knee was the most frequent site of aspiration or injection, followed by the shoulder, hip bursa, and hand/wrist. SI ¼ sacroiliac joint.
http://dx.doi.org/10.1016/j.mayocp.2017.04.007
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this DOAC, likely reflecting the convenience of rivaroxaban relative to dabigatran, which requires a 5-day overlap with intravenous heparin at the time of initiation for acute VTE.14 Patients receiving apixaban before its FDA approval in 2014 likely represent clinical trial participants. Since 2014, there was a shift toward apixaban in our study patients, which may be related to the lower rate of bleeding complications with apixaban.2,15 Our study has several limitations. First, our data are retrospective and derived from a single large medical center database. If patients continued DOAC medications preprocedurally but this use was not documented in the medication list or clinical/procedural notes, these patients may not have been captured within the study population. Assessment of bleeding complications was limited to follow-up encounters occurring within our center’s health care system and would not capture events for which patients sought care at other facilities. However, given the median follow-up of 5 days and that 87.0% of our patients had follow-up encounters within 30 days, it is unlikely that a substantial number of events were not captured. Further, we did not include a control population of either patients taking warfarin or not receiving anticoagulants. Given that general bleeding rates have been consistent in the literature,8-12 it is unlikely that rates would be different in our center because of any unique population factors. This study population did include patients with renal and hepatic failure and those receiving antiplatelet therapy, but there were relatively few such patients, and further study may be necessary to determine the safety of procedures in these populations specifically.
CONCLUSION Overall, the data from this study indicate that patients receiving DOACs at the time of joint or bursa aspirations and injections do not have an increased risk of bleeding complications. Direct oral anticoagulants can safely be continued before these procedures.
1226
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Abbreviations and Acronyms: DOAC = direct oral anticoagulant; FDA = Food and Drug Administration; INR = international normalized ratio; VTE = venous thromboembolism Correspondence: Address to Laura S. Greenlund, MD, PhD, Department of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55902 (greenlund.laura@ mayo.edu).
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