Dry Needling and Antithrombotic Drugs

This narrative review addresses an important clinical question: the safety of dry needling in patients using antithrombotic medications. With the growing use of dry needling in clinical practice for the treatment of pain, increased range of motion, and improved performance, there is a need for clear guidance on its application in patients with altered blood coagulation. The authors performed a comprehensive analysis of the existing literature on antithrombotic medications and their interaction with needling procedures, including comparisons with other needle-based techniques such as electromyography, acupuncture, botulinum toxin injections, and ultrasound-guided biopsies. Antithrombotic medications are classified into two main groups: antiplatelet agents (such as aspirin and P2Y12 blockers) and anticoagulants (including vitamin K antagonists, direct oral anticoagulants, and heparins).

Each class has different bleeding-risk profiles and mechanisms of action. Factors such as age, sex, renal function, and drug-drug or drug-food interactions can influence bleeding risk. Review of studies on other needling techniques provides valuable insights. In electromyography, studies have shown low risk of hematoma even in anticoagulated patients, with an incidence below 2%.

In acupuncture, bleeding-related adverse events were observed in 38.5% of patients on anticoagulants versus 44.4% in the control group, suggesting that the medication does not significantly increase risk. For botulinum toxin injections, an INR up to 2.6 and 27G or smaller needles did not present increased risks. Dry needling has theoretical advantages in terms of safety: it uses solid needles without a cutting bevel, of smaller diameter (35G to 28G), and does not target blood vessels therapeutically. Trigger points, the main target of dry needling, are located near the motor end plates in muscles and fasciae.

Safety studies show that minor adverse events occur in 19.18% of treatments, with bleeding accounting for 16% of these events. Major adverse events are extremely rare (<0.04% per 10,000 treatments). The authors' recommendations include: complete clinical assessment before the procedure, skin inspection for signs of excessive bleeding, starting with superficial muscles before proceeding to deeper muscles, application of prolonged hemostasis (10-15 seconds versus 5 seconds in patients without anticoagulation), and use of ultrasound when available for muscles near major vessels. Anatomic considerations are fundamental, especially when needling muscles such as the lateral pterygoid (near the maxillary artery), tibialis posterior, or psoas major.

The study concludes that antithrombotic medications should not be considered an absolute contraindication to dry needling, provided that specific risks are appropriately taken into account. Discontinuation of medication before the procedure is not recommended, following guidance similar to that of electromyography. This review provides a scientific basis for guiding the safe clinical practice of dry needling in a substantial population of patients on anticoagulants, contributing to the responsible expansion of this therapeutic modality.