Boulias C, Ismail F, Phadke CP, Bagg S, Bureau I, Charest S, Chen R, Cheng A, Ethans K, Fink M, Finlayson H, Gulasingam S, Guo M, Haziza M, Hosseini H, Khan O, Lang M, Lapp T, Leckey R, Li Pi Shan R, Liem N, Lo A, Mason M, McNeil S, McVeigh S, Miller T, Mills PB, Naud P, O'Connell C, Petitclerc M, Prevost J, Reebye R, Richardson D, Satkunam L, Sharma S, Short C, Sirois G, Unarket M, Wein T, Wilkins K, and Winston P
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., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)