Managing Anticoagulant and Antiplatelet Drugs …

1 PL Detail-Document #270503. This PL Detail-Document gives subscribers additional insight related to the Recommendations published in . PHARMACIST'S LETTER / PRESCRIBER'S LETTER. May 2011. Managing Anticoagulant and Antiplatelet Drugs Before Dental Procedures Background or disability due to continuing it during most Patients taking warfarin or Antiplatelet agents dental face an increased risk of bleeding due to dental procedures. But stopping these medications may Managing Bleeding It is recommended that patients taking warfarin put the patient at risk of a thrombotic event ( , or Antiplatelet agents be scheduled early in the DVT, stroke). Therefore, the risk of bleeding day, and early in the week, to facilitate optimal must be weighed against the risk and management of both early and late consequences of thrombosis.

2 This article reviews For patients taking warfarin, the INR should be recommendations for Managing these medications checked within 24 hours before the procedure. in patients requiring a dental procedure. But within 72 hours prior is acceptable if the Recommendations and Rationale patient's INR is generally For help if the Warfarin or aspirin can be continued with local INR is out of range, get our PL Chart, How to hemostatic measures (see below) provided the Manage High INRs in Warfarin Patients. INR is less than 4 during most dental Hemostatic measures include use of a gelatin ,2 These include crowns, bridges, root sponge sutured within the socket, canals, simple extraction of a limited number of vasoconstrictor/anesthetic combinations, and teeth, implants, surgical tooth removal, atraumatic surgical ,3 Having the supragingival scaling, and gingival ,4 patient bite down on gauze sponge/pad for 15 to These recommendations are based on studies of 30 minutes after closure is suggested patients taking warfarin or low-dose aspirin Observe for hemostasis before the patient leaves.

3 Undergoing simple extractions as well as oral A thrombin solution-soaked gel sponge can be There is less data pertaining to bleeding used for persistent Instruct patients risk with clopidogrel, prasugrel (Effient), or to:3,7. dipyridamole, either alone or with ,3,5 The Rest for two or three hours. risk of bleeding with dipyridamole/aspirin is Not disturb the clot with the tongue or any similar to that of aspirin Clopidogrel and object, or by sucking on straws, cigarettes, etc. prasugrel should be handled like aspirin Avoid hot foods/liquids and hard foods for the monotherapy ( , they should not be stopped).3,5 first day. However, patients taking clopidogrel or prasugrel Do not rinse for 24 hours.

4 (and by extension ticlopidine) plus aspirin are at Avoid chewing on the affected side for at least a higher risk of Patients taking such day or two. combinations could be considered for inpatient If bleeding starts, hold pressure with gauze or a management by a dentist or oral surgeon familiar slightly moistened tea bag (black tea) for with these patients. Alteration of Antiplatelet 20 minutes, and call the dentist if it does not therapy is not ,5 At this time, there stop. is no data about the bleeding risk with dabigatran. Avoid NSAIDs for at least 24 hours post Life-threatening bleeding after dental surgery procedure. is The risk of thromboembolism off warfarin for as little as two days may be as high as In addition to these general measures, to 1%.

5 The risk of death or disability due aminocaproic acid solutions have been to holding warfarin is higher than the risk of death recommended for use in warfarin-treated patients. Aminocaproic acid solution is easier to make and More.. Copyright 2011 by Therapeutic Research Center Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249. ~ ~ (PL Detail-Document #270503: Page 2 of 3). is less expensive than tranexamic acid Conclusion In general, tranexamic acid mouthwash is not Current literature does not address stopping recommended. It is expensive, difficult to obtain, cilostazol (Pletal [ only]), heparins, or and has unproven additive benefit when used with dabigatran (Pradaxa; Pradax [Canada]) before other local hemostatic measures including dental procedures.

6 But based on what is known about similar agents, consider continuing them, In one protocol, patients are instructed to hold assuming they are necessary. Patients taking 10 mL of an aminocaproic acid solution for two Antiplatelet combinations could be considered for minutes in the affected area just before the inpatient management. procedure. After the procedure, they are Before a patient taking warfarin has a dental instructed to repeat this every one to two hours procedure, check their INR to ensure it is within until the solution is gone. Make sure that patients the therapeutic range. Discontinue any unneeded hold the solution in the area rather than swish it Antiplatelet agents ( , NSAIDs).

7 And avoid around like mouthwash, which can disturb the prescribing antibiotics that can increase warfarin clot. An aminocaproic acid solution can be made effect ( , erythromycin, clarithromycin, by diluting a 5 gram vial with sterile water for metronidazole).3 Patients at high risk of injection to a total volume of 100 thromboembolism requiring major oral surgery (Aminocaproic acid is not available in Canada.) should be considered for inpatient management [Evidence level C; expert opinion].4. Stopping NSAIDs NSAIDs, including COX-2 inhibitors, have reversible Antiplatelet effects. If the risk of Users of this PL Detail-Document are cautioned to use stopping the NSAID isn't significant, then their own professional judgment and consult any other stopping them before the procedure can lower necessary or appropriate sources prior to making bleeding risk.

8 To ensure absence of Antiplatelet clinical judgments based on the content of this document. Our editors have researched the effect, NSAIDs should be discontinued five half- information with input from experts, government lives before the procedure. The following chart agencies, and national organizations. Information and shows how long before the procedure each internet links in this article were current as of the date NSAID should be of publication. NSAID Time to hold before procedure Levels of Evidence Diclofenac ( , One day before In accordance with the trend towards Evidence-Based Medicine, we are citing the LEVEL OF EVIDENCE. Voltaren), procedure for the statements we publish.

9 Ibuprofen ( , Motrin), Level Definition A High-quality randomized controlled trial (RCT). Indomethacin ( , High-quality meta-analysis (quantitative Indocin), systematic review). Ketoprofen B Nonrandomized clinical trial Nonquantitative systematic review Celecoxib (Celebrex), Two to three days Lower quality RCT. Clinical cohort study Diflunisal, before procedure Case-control study Naproxen ( , Historical control Naprosyn), Epidemiologic study Sulindac ( , Clinoril) C Consensus Expert opinion D Anecdotal evidence Meloxicam ( , Mobic Ten days before In vitro or animal study [ ], Mobicox procedure Adapted from Siwek J, et al. How to write an evidence-based [Canada]), clinical review article.

10 Am Fam Physician 2002;65:251-8. Nabumetone, Piroxicam ( , Project Leader in preparation of this PL Detail- Feldene) Document: Melanie Cupp, , BCPS. More.. Copyright 2011 by Therapeutic Research Center Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249. ~ ~ (PL Detail-Document #270503: Page 3 of 3). References on- Antiplatelet -medication/. (Accessed April 22, 1. Jeske AH, Suchko GD. Lack of a scientific basis 2011). for routine discontinuation of oral anticoagulation 6. Holtzclaw D, Toscano N. Management of the therapy before dental treatment. J Am Dental actively bleeding and hypovolemic dental patient. J. Assoc 2003;134:1492-7. Implant Adv Clin Dent 2009;1:19-27.