Abstract
Objective
To create a consensus statement on the considerations for treatment of anticoagulated
patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity.
Design
We used the Delphi method.
Setting
A multiquestion electronic survey.
Participants
Canadian physicians (N=39) who use BoNTA injections for spasticity management in their
practice.
Interventions
After the survey was sent, there were e-mail discussions to facilitate an understanding
of the issues underlying the responses. Consensus for each question was reached when
agreement level was ≥75%.
Main Outcome Measures
Not applicable.
Results
When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be
withheld regardless of muscles injected; (2) a 25G or smaller size needle should be
used when injecting into the deep leg compartment muscles; (3) international normalized
ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles;
(4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding,
excessive or new bruising, then an INR value on the day of injection with point-of-care
testing or within the preceding 2-3 days should be taken into consideration when injecting
deep compartment muscles; (5) the concern regarding bleeding when using direct oral
anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic
range); (6) the dose and scheduling of DOACs should not be altered for the purpose
of minimizing the risk of bleeding prior to BoNTA injections.
Conclusions
These consensus statements provide a framework for physicians to consider when injecting
BoNTA for spasticity in anticoagulated patients. These consensus statements are not
strict guidelines or decision-making steps, but rather an effort to generate common
understanding in the absence of evidence in the literature.
Keywords
List of abbreviations:
BoNTA (botulinum toxin A), DOAC (direct oral anticoagulant), INR (international normalized ratio)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: May 24, 2018
Footnotes
Disclosures: Chris Boulias, Farooq Ismail, Chetan P Phadke, Robert Chen, Muriel Haziza, Kathryn Wilkins, Thomas Miller, Mark Mason, Lalith Satkunam, Christine Short, Genevieve Sirois, Theodore Wein, and Pierre Naud received funding (research grants, speaker fees, or honoraria) from Allergan; Chetan P Phadke, Farooq Ismail, Chris Boulias, Robert Chen, Muriel Haziza, Mark Mason, Lalith Satkunam, Christine Short, and Genevieve Sirois from Merz; Colleen O’Connell, Mark Mason, Lalith Satkunam, Genevieve Sirois, Theodore Wein, and Pierre Naud from Ipsen; and Isabelle Bureau from Leo Pharma, Pfizer Canada, and Sanofi. The other authors have nothing to disclose.
Identification
Copyright
© 2018 by the American Congress of Rehabilitation Medicine
