As the COVID-19 vaccine continues to be rolled out to the elderly and medically qualified across the country, many questions arise for those who are getting thinner hairs.
The most important point is that the COVID-19 vaccine is OK for almost everyone, whether they have thrombophilia, previous deep vein thrombosis (DVT) or pulmonary embolism (PE), or they are blood thinner.
Reasons for not getting the vaccine must be related to allergies but not to the fact that a patient has had a clot or is on anti – medication. Although COVID-19 infection is associated with an increased risk of DVT and PE, especially in the critically ill and hospitalized patients, there is no reason to believe that the vaccine would risk for blood clots. Recent concerns with post – vaccination thrombotic side effects with the AstraZeneca picture in Europe appear to be opportunistic events, not causally linked to the vaccine.
Most patients do not have to stop taking their antidepressant before they can be vaccinated. The COVID-19 vaccine is given as an injection into the deltoid muscle, just as the flu killed. The diameter of needle used for injection is very accurate, usually diameter 22-25. Intramuscular flu shots in patients on full-dose warfarin (Coumadin, Jantoven) have been shown not to increase the risk for bleeding at the injection site.
Similarly, it is reasonable to assume that the risk for major bleeding into the muscles is also not increased in patients taking direct oral antidepressants – apixaban (Eliquis), dabigatran (Pradaxa), edoxaban ( Savaysa), or rivaroxaban (Xarelto) – or other anticoagulant such as enoxaparin (Lovenox) or fondaparinux (Arixtra).
The FDA’s COVID-19 vaccine factsheet asks patients to tell their provider before receiving the vaccine if they have a bleeding disorder or are thinner in blood but will not give any instructions to the patient. provider. A few formal documents from federal associations and organizations provide useful input.
There is no benefit in vaccinating subcutaneously when it is intended to be given intramuscularly, as this would not alter the risk of inflammation. That’s true even in patients with inflammatory bowel disorder or on antidepressant medication, according to the CDC’s Advisory Committee on Vaccination Practices.
That group recommends prescribing a vaccine before taking the thinner blood for the day, if possible. It is also recommended to use a fine needle (23-gauge or less) and apply strong pressure to the injection site, without rubbing, for at least 2 minutes. The patient or family should be informed of the risk of developing a hematoma.
The International Society of Thrombosis and Haemostasis (ISTH) recommends putting pressure on the site of the longer injection – at least 5 minutes – to reduce the risk for bruising. It also recommends that patients stay on warfarin (Coumadin, Jantoven) until the INR falls below 4.0 before receiving the injection.
For the blood thinner patient, I am a little more cautious than what is reported in the ISTH document. My recommendation is to use a 25 diameter needle or the smallest available caliber. I even recommend the patient ask the injector which measuring needle to use and I will ask for a 25 diameter needle if the response is larger. However, if criterion 25 is not available, vaccination should be carried out with the smallest needle available.
I also recommend considering skipping the morning dose of the blood thinner before vaccination or the evening dose the day before vaccination in case of a drug taken once a day in the evening.
Skimming one dose, or even two, may be particularly useful for the patient who is on one of the above-mentioned blood thinners as well as other antithrombotic, regardless of whether it is aspirin, clopidogrel (Plavix), ticagrelor (Brilinta), or other plate-top drug.
If on warfarin, I recommend measuring INR 2 to 5 days before injection. If the INR is 3 or less, continue vaccination. If it is above 3, consider whether the patient should skip or reduce the next two doses of warfarin or delay the vaccination.
Stephan Moll, MD, is a professor in the Department of Medicine and Department of Hematology at the University of North Carolina at Chapel Hill. He is the medical director of UNC’s Clot Connect education program, where a patient-focused version of this role first appeared.
Last Updated March 12, 2021