title: Acupuncture safety in patients receiving anticoagulants: a systematic review.
abstract: BACKGROUND
  Theoretically, acupuncture in anticoagulated patients could increase bleeding risk. However, precise estimates of bleeding complication rates from acupuncture in anticoagulated patients have not been systematically examined.
  
  
  OBJECTIVE
  To critically evaluate evidence for safety of acupuncture in anticoagulated patients.
  
  
  METHODS
  We searched PubMed, EMBASE, the Physiotherapy Evidence Database, and Google Scholar.
  
  
  RESULTS
  Of 39 potentially relevant citations, 11 met inclusion criteria: 2 randomized trials, 4 case series, and 5 case reports. Seven provided reporting quality sufficient to assess acupuncture safety in 384 anticoagulated patients (3974 treatments). Minor-moderate bleeding related to acupuncture in an anticoagulated patient occurred in one case: a large hip hematoma, managed with vitamin K reversal and warfarin discontinuation following reevaluation of its medical justification. Blood-spot bleeding, typical for any needling/injection and controlled with pressure/cotton, occurred in 51 (14.6%) of 350 treatments among a case series of 229 patients. Bleeding deemed unrelated to acupuncture during anticoagulation, and more likely resulting from inappropriately deep needling damaging tissue or from complex anticoagulation regimens, occurred in 5 patients. No bleeding was reported in 2 studies (74 anticoagulated patients): 1 case report and 1 randomized trial prospectively monitoring acupuncture-associated bleeding as an explicit end point. Altogether, 1 moderate bleeding event occurred in 3974 treatments (0.003%).
  
  
  CONCLUSIONS
  Acupuncture appears to be safe in anticoagulated patients, assuming appropriate needling location and depth. The observed 0.003% complication rate is lower than the previously reported 12.3% following hip/knee replacement in a randomized trial of 27,360 anticoagulated patients, and 6% following acupuncture in a prospective study of 229,230 all-type patients. Prospective trials would help confirm our findings.
authors.affiliation: Research Lead for Integrative Medicine at the Walnut Creek Hospital in CA and a Research Chief at the Pine Street Foundation in San Anselmo, CA. michael.f.mcculloch@kp.org.
authors.forename: Michael
authors.initials: M
authors.lastname: Mcculloch
authors.affiliation: Director of Integrative Medicine at the Walnut Creek Hospital in CA. arian.nachat@kp.org.
authors.forename: Arian
authors.initials: A
authors.lastname: Nachat
authors.affiliation: Research Intern in Integrative Medicine at the Walnut Creek Hospital in CA. jjschwar@princeton.edu.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Schwartz
authors.affiliation: Clinical Nurse Specialist in Integrative Medicine at the Walnut Creek Hospital in CA. vicki.gordon@kp.org.
authors.forename: Vicki
authors.initials: V
authors.lastname: Casella-Gordon
authors.affiliation: Research Intern in Integrative Medicine at the Walnut Creek Hospital in CA. cookjos1@yahoo.com.
authors.forename: Joseph
authors.initials: J
authors.lastname: Cook
mesh_terms: D015670:Acupuncture Therapy / Q000009:adverse effects*; D000925:Anticoagulants / Q000009:adverse effects*; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D012307:Risk Factors; D012449:Safety
chemical_list: D000925:Anticoagulants