anticoags and antiplatelets

Question 1

A 68-year-old male on warfarin for atrial fibrillation attends for extraction of a grossly carious LL6. How would you manage this patient?

Answer 1

Medical History & Risk Assessment

Confirm why the patient is taking warfarin and whether there is a history of bleeding complications.
Check for other medications that could increase bleeding risk, such as aspirin or NSAIDs.
INR Check

INR must be checked within 24–72 hours before the procedure.
If INR <4, proceed with extraction using local haemostatic measures.
If INR ≥4, delay treatment and consult the prescribing physician.
Treatment Modifications

Minimise trauma during extraction.
Use haemostatic agents (e.g., oxidized cellulose, sutures) and give post-op bleeding advice.
Avoid NSAIDs for pain relief; recommend paracetamol instead.

Question 2

A 55-year-old female on apixaban (5 mg twice daily) for a recent deep vein thrombosis (DVT) needs a surgical extraction of LR8. How would you modify her anticoagulant regimen?

Answer 2

Risk Assessment

Apixaban is a direct oral anticoagulant (DOAC) that increases bleeding risk.
Surgical extractions are considered high-risk procedures, so timing of the dose is important.
Dose Adjustment

If taking twice daily apixaban, miss the morning dose on the day of surgery.
If taking once daily apixaban (e.g., rivaroxaban 20 mg once daily), delay the dose until at least 4 hours after haemostasis is achieved.
Intraoperative Haemostasis

Minimise trauma, suture the socket, and use a haemostatic dressing.
Monitor post-op bleeding and review if necessary.