Use in patients being treated with warfarin
According to the Public Health England’s Immunisation Against Infectious Disease (The Green book) the vaccine can be given intramuscularly to individuals on warfarin who are up-to-date with their scheduled INR testing and whose latest INR is below the upper level of the therapeutic range.
A fine needle (equal to 23 gauge or finer calibre such as 25 gauge) should be used for the vaccination, followed by firm pressure applied to the injection site without rubbing for at least two minutes. The patient should be informed of the risk of haematoma from the injection.
If there is any doubt about the level of anticoagulation control, the clinician responsible for prescribing and monitoring the patient’s anticoagulant treatment should be consulted.
Use in patients being treated with a Direct Oral Anticoagulant or DOAC (i.e. apixaban, dabigatran, edoxaban or rivaroxaban)
According to the Green Book the vaccine can be given intramuscularly to individuals who are stabilised on a DOAC.
Advice on reducing the risks of vaccination leading to a haematoma are as described for warfarin above.
Use in patients with bleeding disorders
According to the Green Book the vaccine can be given intramuscularly to individuals with a bleeding disorder. If the patient is receiving regular treatment to reduce bleeding (e.g. patients with haemophilia) vaccine administration can be scheduled to occur shortly after this treatment is given.