| Affiliation: | 1. West Park Healthcare Centre, Toronto, Ontario, Canada;2. Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada;3. Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada;4. Graduate Program in Kinesiology and Health Science, York University, Toronto, Ontario, Canada;5. Providence Care Hospital and School of Medicine, Queen’s University, Kingston, Ontario, Canada;6. Centre for Integrated Health and Social Service (CISSS) for Chaudière-Appalaches Region, Hôtel-Dieu de Lévis, Lévis, Québec, Canada;7. Spasticity Clinic, H Mauricie Center of Quebec, Trois-Rivières, Québec, Canada;8. University Health Network, Toronto, Ontario, Canada;9. Division of Neurology, University of Toronto, Toronto, Ontario, Canada;10. Providence Healthcare, Toronto, Ontario, Canada;11. Winnipeg Health Sciences Centre and Physical Medicine and Rehabilitation, University of Manitoba, Winnipeg, Manitoba, Canada;12. Wascana Rehabilitation Centre and University of Saskatchewan, Regina, Saskatchewan, Canada;13. GF Strong Rehabilitation Center and Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada;14. Physiatry Clinic, CDN Institute of Rehabilitation, Montreal, Québec, Canada;15. Regional Rehabilitation Centre, Hamilton, Ontario, Canada;p. Hotel Dieu Shaver, St. Catharines, Ontario, Canada;q. Halton Healthcare, Milton, Ontario, Canada;r. Muskoka Algonquin Health Care and Northern Ontario School of Medicine, Sudbury, Ontario, Canada;s. Stan Cassidy Centre, Fredericton, New Brunswick, Canada;t. Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Nova Scotia, Canada;u. Foothills Medical Centre, Calgary, Alberta, Canada;v. University of Calgary, Calgary, Alberta, Canada;w. Hôtel-Dieu Grace Healthcare, Windsor, Ontario, Canada;x. Oshawa Clinic, Oshawa, Ontario, Canada;y. Nova Scotia Rehabilitation Centre, Halifax, Nova Scotia, Canada;z. St. Joseph’s Health Care London, Western University, London, Ontario, Canada;11. Capital Health Complex, Quebec City, Québec, Canada;22. Neuro-Lévis Neurology Clinic, Lévis, Québec, Canada;33. Saint-Jérôme Regional Hospital, Saint-Jérôme, Québec, Canada;44. Glenrose Rehabilitation Hospital and Division of Physical Medicine & Rehabilitation, University of Alberta, Edmonton, Alberta, Canada;55. Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada;66. Quebec of Institute of Rehabilitation and Physical Impairment and Laval University, Québec City, Québec, Canada;77. Montreal General Hospital and McGill University, Montreal, Québec, Canada;88. Aviva Medical, Barrie, Ontario, Canada;99. CBI Health Centre, Victoria, British Columbia, Canada |
| Abstract: | ObjectiveTo create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity.DesignWe used the Delphi method.SettingA multiquestion electronic survey.ParticipantsCanadian physicians (N=39) who use BoNTA injections for spasticity management in their practice.InterventionsAfter 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 MeasuresNot applicable.ResultsWhen 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.ConclusionsThese 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. |
