anticoagulants and antiplatelets Flashcards
general advice for tx likely to cause bleeding
plan tx early in day and week atraumatic tx local haemostatic measures only discharge once haemostasis achieved written post-tx advice emergency contact if travel time concern, emphasise measures to avoid complications
if meds aren’t lifelong/long-term
delay dental tx where possible
consult GP
give 3 vit K antagonists
warfarin
acenoconmarol
phenindione
treating pts on vit K antagonists
check INR within 24hrs (up to 72hrs if stably anti coagulated)
if INR below 4
- tx without interrupting meds
- consider staging extensive/complex tx
- actively consider suturing and packing
INR 4 or above
- delay tx, refer if urgent
taking anti platelets - just aspirin
tx without interrupting meds
consider staging extensive/complex procedures
local haemostatic measures
consider limiting initial tx area
taking clopidogrel/dipyridamole/prasugrel/ticagrelor single or dual (with aspirin)
tx without interrupting meds expect prolonged bleeding consider staging extensive/complex procedures actively consider suturing and packing limit initial tx area
name 4 DOACs
dabigatran
apixaban
rivaroxaban
edoxaban
NOACs general advice
advise pt to miss/delay morning dose before tx
tx early in day
limit initial tx area and assess bleeding before continuing
stage extensive/complex procedures
actively consider suturing and packing
advise pt when to restart meds
pt taking injectable AC/other drug combinations
dalteparin, enoxaparin, tinzaparin
prophylactic (low dose) - tx without interrupting meds
tx (higher dose) or uncertainty about the dose: consult w the prescribing clinician for more info
consider limiting initial tx area and staging extensive or complex procedures, strongly consider suturing and packing
procedures unlikely to cause bleeding
LA (inc blocks) BPE supra gingival scaling restorations with supra gingival margins orthograde endo pros ortho appliances
procedures likely to cause bleeding - low risk
simple extractions (1-3 teeth, restricted wound size) I+D of IO swellings 6PPC RSI and sub gingival scaling restorations with sub gingival margins
procedures likely to cause bleeding - higher risk
complex extractions, adjacent extractions that will cause a large wound, >3 flap raising procedures - elective surgical extractions - PD surgery - pre-prosthetic surgery - periradicular surgery - crown lengthening - implant surgery - gingival recontouring - biopsies
apixaban action
inhibitor of factor Xa
rivaroxaban action
inhibitor of factor Xa
dabigatran action
direct thrombin inhibitor
NOAC dose schedules for high risk procedures - apixaban
normal x2 per day miss morning pre-tx dose take normal evening dose - as long as >4hrs since haemostasis achieved continue normal drug schedule after
NOAC dose schedules for high risk procedures - dabigatran
normal x2 per day miss morning pre-tx dose take normal evening dose - as long as >4hrs since haemostasis achieved continue normal drug schedule after
NOAC dose schedules for high risk procedures - rivaroxaban if usual dose x1 in morn
delay morning dose
take 4 hours post-haemostasis
continue normal drug schedule after
NOAC dose schedules for high risk procedures - rivaroxaban if usual dose x1 in evening
take at usual time in evening as long as >4hrs since haemostasis achieved
continue normal drug schedule after
do not interrupt anticoagulant/antiplatelet therapy for
pts with prosthetic metal heart valves or coronary stents
pts who have had a PE or DVT in the last 3m
pts on anticoagulant therapy for cardioversion
are LAs likely to cause bleeding?
no
which DOACs are taken twice a day?
apixaban and dabigatran
which DOACs are taken once a day/
rivaroxaban and edoxaban
NOAC dose schedules for high risk procedures - edoxaban if usual dose x1 in morn
delay morning dose
take 4 hours post-haemostasis
continue normal drug schedule after
NOAC dose schedules for high risk procedures - edoxaban if usual dose x1 in evening
take at usual time in evening as long as >4hrs since haemostasis achieved
continue normal drug schedule after
anticoagulant/antiplatelet combinations
consult with pts prescribing clinician in order to assess the likely impact of the particular drug combination and the pts medical condition on their bleeding risk
env considerations
pt travel - minimise wasted appts and unnecessary travel
- confirm MH in advance e.g. by phone to check for any changes that could impact tx and require postponement
- consult with doctor in advance of appt if more info required
- provide pre and post tx instructions (electronically, written if required)
- suture and pack at time of tx - this may reduce likelihood of pt having to reattend for management of post-op bleeding
