Anticoagulants and antiplatelets Flashcards
What MH would you take for warfarin
- why do you take anticoagulant
- whats your dose, freq, route of warfarin
- do you know your most recent INR, when was it taken
- do you have your yellow book with you (look for stable INR of less than 4)
- do you have the contact details of your coagulation clinic
- have you had any bleeding problems in the past
- any family history of bleeding problems
whats the half life of warfarin
approx 48 hours
why shouldn’t you stop warfarin the day before an extraction
- the risk of stopping warfarin outweigh risks of prolonged bleeding
- it takes around 2 days for the changes in the oral dose of warfarin to affect the INR
- if you’re in the therapeutic range there is no risk of post-operative bleeding
what steps do you need to take with someone to ensure no prolonged bleeding
- your INR will be checked less than 24 hours before extraction, okay to proceed if less than 4
- surgicel pad placed to into socket, helps to stop bleeding
- dissolvable sutures will be placed after the extraction
- give gauze to bite down on
- tranexamic acid MW if req- helps coagulation
- contact number if prolonged bleeding occurs
what post-operative pain medication can they take
- paracetamol
- codeine
- co-codamol
what post-operative pain medication can they not take
- NSAIDs e.g. ibuprofen, aspirin, naproxen
- COX-2 inhibitors
Which 4 antimicrobial drugs interact adversely with warfarin
what effect do they have
- erythromycin
- metronidazole
- fluconazole
- miconazole
bleeding risk increases
which guidelines do you refer to for anticoagulants and antiplatelets
SDCEP
what is the general advice for patients taking anticoagulants and antiplatelets requiring dental tx likely to cause bleeding
- plan tx for early in the day and week
- only discharge pt when haemostasis has been achieved
- provide pt with post tx advice and emergency contact details
flow chart
- Is dental treatment likely to cause bleeding?
no= treat with caution using standard procedures, taking care to avoid causing bleeding
yes= q2 - Is medication time-limited?
yes= delay non-urgent, invasive dental procedures where possible
no= q3 - Does patient have other relevant medical complications?
yes= consult with prescribing clinician, specialist or general medical practitioner, if required
no= which drug type is the patient taking?
5 procedures with low risk of post operative bleeding complications
- simple extractions (1-3)
- incision and drainage of IO swellings
- 6PPC
- RSD
- restorations with subgingival margins
4 procedures with high risk of post operative bleeding complications
- complex extractions/3+ extractions
- flap raising procedures
- gingival recontouring
- biopsies
name 4 DOACs
apixaban
dabigatran
rivaroxaban
edoxaban
if a pt is taking DOACs, what do you do if they have a low bleeding risk
- treat without interrupting medication
- treat early in day, limit initial treatment area and assess bleeding before continuing, consider staging extensive or complex procedures, strongly consider suturing and packing
if a pt is taking DOACs, what do you do if they have a high bleeding risk
- advise pt to miss or delay morning dose before tx
- treat early in day, limit initial treatment area and assess bleeding before continuing, consider staging extensive or complex procedures, strongly consider suturing and packing
- advise pt to restart their medication
for pt’s taking DOACs, what is the
- usual drug schedule
- pre-tx dose
- post-tx dose
apixaban/dabigatran
- 2x/day
- miss morning dose
- usual time in evening
rivoroxaban/edoxaban
- once a day, morning
- delay morning dose
- 4 hours after haemostasis has been achieved
OR
- once a day, evening
- not applicable
- usual time in evening
3 examples of vitamin K antagonist
- warfarin
- acenocoumarol
- phenindione
what do you do with a patient who takes a vitamin K antagonist
- Check INR (up to 24 hours before procedure and up to 72 hours if pt is stably anticoagulated)
- If INR below 4 treat without interrupting medication
- strongly consider suturing and packing - if INR 4 or above, delay invasive tx or refer if urgent
give 3 examples of injectable anticoagulant
- dalteparin
- enoxaparin
- tinzaparin
Drug interactions between anticoagulants or antiplatelet drugs and other medications
what do you do with a pt who is on a prophylactic low dose of an injectable anticoagulant
- Treat without interrupting medication
- Consider limiting initial treatment area and staging extensive or complex procedures, strongly consider suturing and packing
what do you do with a pt who is on a prophylactic high dose of an injectable anticoagulant
Consult with prescribing clinician for more information
give 5 examples of antiplatelet drugs
- aspirin
- clopidogrel
- dipyridamole
- prasugrel
- ticagrelor single or dual therapy (in combination with aspirin)
what do you do with a pt who takes aspirin alone
Treat without interrupting medication
what do you do with a patient who takes clopidogrel, dipyridamole, prasugrel or ticagrelor single or dual therapy (in combination with aspirin)
Treat without interrupting medication
what do you do if a pt takes an anticoagulant/antiplatelet combination
Consult with the patient’s prescribing clinician to assess the likely impact of the particular drug combination and the patient’s medical condition on their bleeding risk
