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Acupuncture
In Patients
Anticoagulated With Warfarin
Joseph Sciammarella, MD
ABSTRACT
Background Although there have been no reported cases
of bleeding-related complications due to acupuncture in anticoagulated
patients, practitioners traditionally have been taught to be aware of
possible bleeding complications in this subgroup of patients.
Objective To review the experience of performing acupuncture
in patients who were anticoagulated with oral warfarin sodium.
Design, Setting, and Patients Retrospective chart review of the
outcomes of 4 women who presented to a solo-practice physician's office
to receive acupuncture for pain relief. All 4 patients were receiving
warfarin for underlying conditions.
Intervention A total of 51 acupuncture treatments without electrical
stimulation at local and distal acupuncture points.
Main Outcome Measures Objective assessment of prolonged bleeding
after needle withdrawal, patient reports of any symptoms of post treatment
bleeding-related problems, and post-treatment observation of hematoma
or ecchymosis.
Results None of the patients demonstrated any post-treatment
bleeding or bleeding-related problems, either as observed by the physician-acupuncturist
or through self-report.
Conclusion Acupuncture appears safe to perform on patients taking
warfarin for anticoagulation.
KEY WORDS
Acupuncture, Anticoagulation, INR, Prothrombin Time, Warfarin
INTRODUCTION
In 1924, Schofield reported a hemorrhagic disorder in cattle that resulted
from the ingestion of sweet clover. In 1939, Campbell and Link identified
this hemorrhagic agent as bishydroxycoumarin. When a more potent form
of this agent was synthesized in 1948, it was named warfarin, an acronym
derived from the name of the patent holder, Wisconsin Alumni Research
Foundation (WARF), plus the coumarin-derived suffix.1
Today, warfarin
sodium is the most frequently used oral anticoagulant for the control
and prevention of thromboembolic disorders.2 It is the 11th most-prescribed
drug in the United States.3
The anticoagulant
effect of warfarin is due to its antagonism of vitamin K. Vitamin K
is required to synthesize clotting factors II, VII, IX, and X, and also
for the synthesis of the anticoagulant proteins C and S.
Bleeding is
the major adverse effect of oral anticoagulants. Any activities or procedures
that may cause bleeding must be carefully considered in patients taking
warfarin. Although there have been no reported cases of bleeding-related
complications from acupuncture being performed on anticoagulated patients,
practitioners are taught to be aware of possible bleeding complications
in this subgroup of patients.4
CASE REPORTS
In all patients, acupuncture without electrical stimulation was performed
at both local and distal points using 0.25- x 40-mm needles.
Consent was obtained in every case.
Case 1
A 77-year-old woman presented with a history of coronary artery disease;
she had undergone 2-vessel coronary artery bypass graft (CABG) surgery.
The patient was referred by a neurosurgeon for medical acupuncture to
treat chronic low back pain with sciatic radiculopathy. Magnetic resonance
imaging (MRI) revealed diffuse disk space narrowing and desiccation
throughout the lower dorsal and lumbosacral spine. Bulging disks were
noted posteriorly throughout the lumbar spine. She was receiving 2.5
mg/d of warfarin.
Over a 5-week
period, the patient received a total of 9 acupuncture treatments. Her
prothrombin time during the series of treatments was 17.3 seconds (normal,
11.5-13.5 seconds), and her international
normalized ratio (INR) was 2.2 (target INR for standard-dose antico-
agulation, 2.0-3.0).
Case 2
A 56-year-old woman presented with a history of atrial fibrillation
and 2 coronary artery bypass graft (CABG) surgeries over a 10-year period.
Previously, the patient had 2 cervical disk removals with grafting,
but she continued to have chronic neck and shoulder pain. A cardiologist
referred her for medical acupuncture for pain relief. She was receiving
5 mg/d of warfarin, 5 days each week.
The patient
received 23 acupuncture treatments over a 14-week period. Her prothrombin
time during acupuncture treatments was 33.6 seconds, and her INR was
2.8.
Case 3
An 84-year-old woman presented with a history of congestive heart failure
and a non-hemorrhagic cerebrovascular accident, from which she completely
recovered. The patient was referred by an internist for medical acupuncture
to treat chronic pain in her right shoulder. Prior to receiving acupuncture,
she was taking 2.5 mg/d of warfarin. However, her prothrombin time was
only 13.7 seconds and her INR was only 1.19, so the warfarin dosage
was increased to 5 mg/d.
The patient
received a total of 9 acupuncture treatments over a 13-week period.
Her follow-up prothrombin time was 27.8 seconds, and her INR had increased
to 4.9.
Case 4
A 75-year-old woman presented with a history of cardiac surgery to replace
2 heart valves. An internist referred her for medical acupuncture for
pain relief from chronic low back pain with sciatic radiculopathy. MRI
revealed spinal stenosis. She was receiving 4 mg/d of warfarin.
The patient
received a total of 10 acupuncture treatments over a 5-week period.
Her prothrombin time was 18.3 seconds and her INR was 2.6. She experienced
occasional asymptomatic ecchymosis at the acupuncture site on her upper
back. The ecchymosis was no greater than that normally seen in acupuncture
patients.
DISCUSSION
Warfarin is the most frequently prescribed oral anticoagulant for the
control and prevention of thromboembolic disorders. Often, anticoagulated
patients are not candidates for certain surgical procedures. Nor are
they eligible for some classes of analgesic medications, such as non-steroidal
anti-inflammatory drugs, because of the increased bleeding risks associated
with concomitant warfarin use. Many of these patients seek out or are
referred for acupuncture as an alternative to surgery or pharmacotherapy.
Although there
have been no reported cases of bleeding-related complications from acupuncture
being performed on anticoagulated patients, practitioners have been
taught to be aware of possible bleeding complications in this subgroup
of patients. Any activities or procedures that may cause bleeding must
be carefully considered.
This case series
reviewed the outcomes of acupuncture performed on 4 female patients.
These patients were all taking oral warfarin sodium for their underlying
medical conditions: 1 had 2 mechanical heart valves, 1 had atrial fibrillation,
1 had a non-hemorrhagic cerebrovascular accident, and 1 had coronary
artery disease. Although the sample size is small, collectively, 51
acupuncture treatments were performed.
During the course
of treatment, all 4 patients were anticoagulated to a therapeutic range
of prothrombin time prolongation beyond the normal range, and INR prolongation
into the target range for standard-dose anticoagulation. One patient
was found to be excessively anticoagulated, with an INR of 4.9.
During the course
of the 51 treatments, none of the patients demonstrated any post-treatment
bleeding, either as observed by the physician-acupuncturist or by self-report.
Only one patient was noted to have an occasional asymptomatic ecchymotic
area at an acupuncture site on the upper back.
CONCLUSION
Acupuncture appears safe to perform on patients receiving warfarin sodium.
Because of its benign nature, acupuncture may be the preferred treatment
modality for anticoagulated patients who are not candidates for surgery
or pharmacotherapy because of the increased bleeding risks associated
with concomitant warfarin use.
REFERENCES
1. Hardman JG, Limbird LE, eds. Goodman & Gilman's The Pharmacologic
Basis of Therapeutics. 9th ed. New York, NY: McGraw-Hill; 1996:1346-1347.
2. Horton JD, Bushwick BM. Warfarin therapy: evolving strategies
in anticoagulation. Am Fam Physician. 1999;59:635-646.
3. National Prescription Audit: Physician Specialty Report, Dispensed
Data. Plymouth Meeting, Pa: IMS America; 1998.
4. Helms JM. Acupuncture Energetics: A Clinical Approach for
Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995:56.
AUTHOR INFORMATION
Dr Joseph Sciammarella is a Diplomate of the American Boards of Internal
Medicine and Emergency Medicine, and a Diplomate of the American Academy
of Pain Management. He is a Fellow of the American College of Physicians
and the American College of Emergency Physicians. Dr Sciammarella is
in private practice in Rockville Centre, New York, specializing entirely
in Medical Acupuncture. He is the founding President of the New York
State Chapter of the American Academy of Medical Acupuncture (AAMA).
Joseph Sciammarella,
MD, FACP, FACEP
30 Hempstead Ave, Suite 244
Rockville Centre, NY 11570
Phone/Fax: 516-594-1057 • E-mail: DrJoe@MDacupuncture.net
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