An anticoagulant is a medicine that slows blood clotting: warfarin, heparin, and the direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban and dabigatran. Antiplatelet drugs such as aspirin and clopidogrel act on the platelets, the blood cells that start a clot. Two kinds of record describe what happens when people taking them, or people whose blood clots poorly for another reason, have acupuncture. Cohort studies count the small bleeds at the needle site across hundreds or millions of treatments. Case reports describe single serious bleeds, nearly all of them deep in a muscle or near the spine. The guidance written on the subject ranges from avoiding needling altogether to needling once the dose is stable, and this page reports each in turn. How often bleeding and bruising occur in acupuncture patients generally is on After a treatment. Dry eye disease reports severe bruising around the eye after acupuncture for dry eye, in one case in a woman taking daily aspirin.
People taking anticoagulants
A 2015 systematic review by Michael McCulloch and colleagues at Walnut Creek Hospital in California found 11 studies, of which 7 reported in enough detail to judge safety: 384 people on anticoagulants who had 3,974 treatments between them. The reviewers attributed one bleed to acupuncture, a large haematoma at the hip in a patient on warfarin, treated by reversing the warfarin with vitamin K and stopping it. Their abstract gives the rate as 0.003%; one in 3,974 is 0.025%. Studies published since then are set out below.
| Study | People and treatments | What it counted | Result |
|---|---|---|---|
| Miller and colleagues, US hospital, 2012 | 229 inpatients on warfarin, 350 treatments, each with a blood test (INR) the same day | Any bleeding noted at a needle site | Bleeding in 51 treatments (14.6%), 50 of them cleaned up with a cotton bud; 14.3% when the INR was above 2.3 and 14.6% when it was below |
| Lee and colleagues, Korea, 2018 | 428 inpatients, 169 of them on anticoagulant or antiplatelet drugs | Small bleeds, haematoma and bruising, prospectively | 38.5% of those on the drugs and 44.4% of those not on them; no difference in risk per session. Only a thicker needle raised the risk |
| Kwon and colleagues, Korea, 2018 | 316 stroke patients, 10,177 sessions; 28 on a DOAC (1,076 sessions) | Bleeding that stopped within 30 seconds of removing the needle | 3.9% of sessions on a DOAC, 5.6% on an antiplatelet drug, 5.1% on neither; no major bleeding |
| Hsieh and colleagues, Taiwan, 2023 | 821,946 people, 13,447,563 sessions, from national health insurance records 2000 to 2018 | Bleeding recorded in the 14 days after a session | Minor bleeding 8.31 per 10,000 needles, major bleeding 4.26 per 100,000 needles |
The Taiwanese study compared the drugs one by one. It found that anticoagulants as a group raised the odds of minor bleeding by 15%, with no significant change in major bleeding. Taken drug by drug, the odds of bleeding were about 5 times higher with warfarin, 3 times with DOACs and 3.7 times with heparin, while antiplatelet drugs made no significant difference. Liver cirrhosis, diabetes and clotting defects were also risk factors. The smaller cohorts found no difference, and the Korean DOAC study excluded anyone whose INR, the standard measure of how far warfarin has slowed clotting, was above 3.0.
Serious bleeds in case reports
The serious bleeds reported in people on anticoagulants are single cases, in a muscle or around the spinal cord:
- An 82-year-old woman on warfarin for atrial fibrillation developed a large haematoma in the thigh after community acupuncture for trochanteric bursitis; her INR at the time of needling was 2.4.
- A stroke patient with atrial fibrillation developed a haematoma in the calf once the INR reached its target; it was treated without surgery and had cleared by three months.
- A 69-year-old man developed a subdural haematoma in the cervical spine two hours after acupuncture to the neck and back; surgery was scheduled within two days of the diagnosis because of previous anticoagulant therapy, took place on the ninth day after a delay the patient chose, and he had recovered fully three months later.
Haemophilia
Haemophilia is an inherited shortage of a clotting factor, factor VIII or IX. A 2025 systematic review found four studies of acupuncture for joint pain in haemophilia, covering 37 patients, and none reported a significant bleed. In one of them, from Bonn, 12 patients with factor VIII activity below 1% had a single needle placed at the rear fontanelle of the skull once a week for 15 weeks, and the authors observed no side effects. In another, from the haemophilia treatment centre at Henry Ford Hospital in Detroit, 9 patients each had a course of 14 treatments, some after a dose of clotting factor and some without, and none bled or bruised. The authors of a 2002 case report recommend that only practitioners with special training treat people with haemophilia, in close co-operation with a haemophilia clinic.
Low platelet counts
Chemotherapy and blood cancers can lower the platelet count, a condition called thrombocytopenia. Four cancer centres have reported what happened when they needled patients whose counts were low.
| Study | Sessions at low counts | Bleeding reported |
|---|---|---|
| Ladas and colleagues, New York, 2010: 32 children and adolescents, 237 sessions | 20% of sessions at severe, 8% at moderate and 19% at mild thrombocytopenia | None |
| Cybularz and colleagues, Philadelphia, 2015: 684 adults, 2,135 visits | 98 visits below 100,000 per microlitre, 9 of them below 50,000 | No increased bruising or bleeding |
| Kayo and colleagues, Fukushima, 2024: 51 patients with blood cancers, 815 sessions analysed | 90 sessions below 20,000 and 161 between 20,000 and 49,000 | No bleeding of grade 2 or worse within 24 hours |
| Martínez García and colleagues, Barcelona, 2026: 196 children and young adults, 1,107 sessions with semi-permanent needles | 305 sessions during thrombocytopenia | One superficial haematoma of the ear, in a patient with grade 4 (the most severe) thrombocytopenia, which resolved without treatment |
A single 2006 report from Germany describes the opposite outcome. A 78-year-old man treated for pain after surgery with needles embedded in the ear developed haematomas of the ear four days later, which the authors attribute to a fall in his platelet count as fluids diluted his blood after the operation. A 2013 review of case reports records that he recovered with some discolouration.
What guidance says
The WHO’s 1999 Guidelines on basic training and safety in acupuncture advise that needling be avoided in people with bleeding and clotting disorders and in people on anticoagulant therapy or drugs with an anticoagulant effect. The WHO’s 2020 benchmarks for the practice of acupuncture list a disturbance of blood coagulation as a contraindication, and ask practitioners withdrawing needles from areas that tend to bleed to press the site with a clean swab. The NHS page on complementary therapies says acupuncture may not be safe for someone taking blood-thinning medicine or at increased risk of bleeding. The British Acupuncture Council’s Code of Safe Practice (2016) does not name anticoagulants; it requires a full medical history from every new patient and light pressure with sterile cotton wool where a needle draws blood.
The most detailed guidance comes from oncology. Recommendations for safe acupuncture in cancer care published in 2024 by an international panel, whose authors include staff of the British Acupuncture Council and the British Medical Acupuncture Society, state that:
- published expert opinion gives a platelet count of 20,000 per microlitre as a safe cut-off, below which needles should be used only with the agreement of the oncology team;
- acupuncture should be used with caution while a patient’s warfarin dose is still being adjusted, and can be given once the dose is stable and the INR is in range, after telling the patient about a slightly higher risk of minor bruising or bleeding;
- most other anticoagulants, the DOACs and low molecular weight heparin among them, reach their working dose at once;
- acupuncture should be avoided where there is spontaneous bleeding, bruising or haematoma, and vigorous needling into the enclosed muscle compartments of the leg or into joint spaces should be avoided when the risk of bleeding is raised.
A point page on AcuiQ prints a caution about bleeding disorders wherever a source gave one; Reading a point warning explains how to read a caution that depends on the patient rather than on the point.
What the sources cannot tell you
No randomised trial has compared bleeding in anticoagulated people who did and did not have acupuncture. The studies of DOACs rest on 28 patients in one Korean cohort and on insurance claims in Taiwan, which record a bleed only when it was diagnosed and coded. One Korean cohort pooled anticoagulant and antiplatelet drugs, and the other excluded people taking warfarin. The haemophilia evidence covers 37 patients, and the platelet studies are retrospective reviews of records at single centres. The case reports show what can happen but carry no denominator. AcuiQ’s entries record what a study prescribed, not the medicines its participants took or what happened to them; What AcuiQ does not do sets out that limit.