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To stop or not to stop anticoagulants in patient prior to dental surgery?

Lanca A J resized

Dr. Jose Lança, from the Faculty of Dentistry and the Faculty of Medicine at the University of Toronto, speaks with Dr. John O’Keefe about the important decisions dentists need to make when treating patients who are on anticoagulants and who need dental surgery: should they, or not, ask the patient to stop taking their anticoagulant medication?

Highlights

  • The monitoring of warfarin anticoagulation is aimed at conventional anticoagulation INR of 2.0-3.0 (normal INR:0.9-1.1). Intensive anticoagulation is defined as an INR of 2.5-3.5, and critical values of >4.5-5.0.
  • Do not be quick in discontinuing oral anticoagulants just because the patient might experience a bit more bleeding during or after dental surgery.
  • What outweighs in terms of benefits for the dentist may result in serious risk or damage for the patient.
  • The dentists should inform the patient about the risk of more bleeding prior to the surgery and should explain that this risk is mainly due to the fact that they are on anticoagulation therapy.

The drug names mentioned, in addition to warfarin (a vit. K antagonist) and low dose acetylsalicylic acid (Aspirin®) (platelet aggregation inhibitor) are as follows:

Inhibitors of platelet aggregation

  • Clopidogrel (Plavix®) – platelet aggregation inhibitor
  • Dipyridamole (Persantine®) – Inhibitor of Platelet Adhesion and Aggregation and coronary vasodilator

Anti-hemorrhagic

  • Tranexamic acid  (Cyclokapron®) – antifibrinolytic

New/Novel Oral Anticoagulants (NOACs) (shorter half-life than warfarin)

  • Dabigatran (Pradaxa®) – anticoagulant, direct thrombin inhibitor
  • Rivarobaxan (Xarelto®) – anticoagulant, Factor Xa inhibitor

Selective inhibitor for NOAC Dabigatran (Pradaxa®)

Note: a selective inhibitor for Rivarobaxan (Xarelto®) is currently in phase 3 clinical trials.

 

Full Interview

 

Dr. Lanca’s Presentation

 

Dr. Lanca’s COncluding Remarks

 

Additional Resources

 

3 comments

  1. Dr. Vasant Ramlaggan

    Thanks for this excellent interview and presentation! It was very informative and will be extremely useful in our everyday practise!

  2. Since we have no way of measuring the new anticoagulants effectiveness( i.e. INR re warfarin) how do we know whether we are in a safe therapeutic range to perform routine dental surgery re (Pradaxa,Eliquis,Xarelto), and how do we assess patient risk for bleeding, also knowing full well there are no approved antidotes in Canada for these drugs? Or do we just discontinue them for 1-3 days prior as recommended by American Heart and live with the risk of stroke in these patients?

  3. Dear Dr. Haslam,

    Thank you for your comments.

    Three brief points.

    First, Praxbind, as entered on my list of resources is available in Canada since April 2016. Please check RxTx (formerly know as e-CPS).

    Second, discontinuation of the anticoagulant is not appropriate, as this unnecessarily increases the risk of severe, and potentially fatal complications. The reasoning, resources and updated guidelines are provided in detail in my presentation.

    Third, INR values are not altered at all by novel oral anticoagulants (NOACs) (e.g., Pradaxa, Xarelto) and therefore INR is not a valid test to monitor anticoagulation by NOACs.

    I will specifically discuss NOACs in an upcoming CDA Oasis presentation.

    Sincerely,

    Dr. Jose Lanca, MD, PhD

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