What is the Relevance of the Novel Anti-Coagulants (NOACs) to the Dental Practice?

Dr. Jose Lança, MD. PhD, Assistant Professor, Pharmacology  in the Faculty of Dentistry and the Faculty of Medicine at the University of Toronto, spoke with Dr. John O’Keefe about the new anti-coagulant drugs on the market and their relevance to dental practice.

Highlights

There are newer oral anticoagulants (NOACs), direct oral anticoagulants, available on the market for patients and are becoming increasingly common. These newer drugs have been available for ~5-6 years and have a different mecahnisms of action than warfarin as well as several benefits for patients. These drugs directly target and inhibit the coagulation pathways, specifically thrombin or Factor X. Examples include: Eliquis, Pradaxa, and Xarelto.

The use of these drugs is very common and they have fewer limitations than other anticoagulants and they have “de-throned” warfarin as the anti-coagulant of choice.

Indications
• Treatment and prevention of deep vein thrombosis and pulmonary embolism
• Prevention of stroke in patients with non-valvular or atrial fibrillation
• Postoperative thrombophylaxis after hip or knee replacements

Medications mentioned in the presentation

Novel Oral Anticoagulants (NOACs)

• shorter half-life than warfarin
• direct inhibition of the coagulation cascade
  • Dabigatran (Pradaxa®) – Anticoagulant, direct thrombin inhibitor
  • Rivarobaxan (Xarelto®) – Anticoagulant, Factor Xa inhibitor
  • Apixaban (Eliquis®) – Anticoagulant, Factor Xa inhibitor

Selective inhibitor for Dabigatran (Pradaxa®)

• Idarucizumab (Praxbind®) – monoclonal antibody, selective antidote for Dabigatran (Pradaxa®).
• Approved by the FDA since October 2015. Approved by Health Canada in April 2016

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

Anti-hemorrhagic

Tranexamic acid (Cyclokapron®) – Hemostatic/Antifibrinolytic

Shortcomings
• Risk of bleeding increased in patients >75yrs of age
• Increased GI bleeding with high dosing of Pradaxa
• Increased dyspepsia with use of Pradaxa
• Lack of reliable lab tests to measure levels of NOACs
• Selective antidote for Pradaxa but, not for the other Factor X antagonists

Benefits
• Broad therapeutic window compared to warfarin
• Safer than warfarin with respect to bleeding risks
• Reduce total cardiovascular mortality
• Decrease intracranial bleeding
• Short half-life of drug
• Reliability of anticoagulation that is achieved by administration
• Taken once or twice a day by patients
• Coagulation monitoring is not required
• Predictable anticoagulation is achieved quickly and do not have to wait for days
• Dose is very reliable and does not have to change much from patient to patient
• Few known food and drug interactions

Dental Implications
When treating patients and planning or performing surgery on patients taking these medications, it is important to follow current guidelines, consider the individual risk-benefit profile of the patient and consult with the patient’s medical doctor.

Watch the video presentation