Pharmacist's Letter - Article Flashcards
What is the point of this article?
Reviewing recommendations for managing warfarin or antiplatelet medications vs risk of thrombotic events for patients requiring a dental procedure
Recommendations and Rationale
Warfarin or aspirin can be continued with local hemostatic measures provided the INR is less than what?
Less than 4 during most dental procedures
Procedures like:
- Crowns, bridges, root canals, simple extractions, implants, surgical extractions, supragingival scaling, and gingival surgery.
Recommendations and Rationale
Is alteration of antiplatelet therapy recommended?
No, not recommended.
Recommendations and Rationale
Which has higher risk for thromboembolism:
- Risk of death or disability due to holding warfarin
- Risk of death or disability due to continuing it during most dental procedures
Holding warfarin has higher risk of thromboembolism
Managing Bleeding
When should patients taking warfarin or antiplatelet agents be scheduled?
Early in the day and early in the week to facilitate optimal management of both early and late re-bleeding.
Managing bleeding
When should patient’s INR (who take warfarin) be checked?
Within 24 hours before procedure (but within 72 is acceptable if patient’s INR is generally stable).
Managing bleeding
What are some of the hemostatic measures recommended?
- Use of a gelatin sponge sutured within the socket
- Vasoconstrictor/anesthetic combinations
- Atraumatic surgical techniques
- Having patient bite down on gauze sponge/pad for 15 to 30 minutes after closure
- Observe for hemostasis before patient leaving
- Thrombin solution-soaked gel sponge can be used for persistant bleeding
Managing bleeding
What should patients be instructed to do post-op?
- Rest for two or three hours
- Not disturb the clot with tongue or any object
- Avoid hot foods/liquids and hard foods for first day
- Avoid chewing on affected side for a day or two
- If bleeding starts, hold pressure with gauze or slightly moistening black tea bag for 20 minutes - call dentist if it does not stop
- Avoid NSAIDS (aspirin, ibuprofen)
Managing bleeding
In addition to general measures, solutions of what chemical are recommended for use in warfarin-treated patients?
Aminocaproic acid - easier to make and less expensive than tranexamic acid solution
Managing bleeding
Why is aminocaproic acid solution recommended over tranexamic acid solution?
- Easier to make/obtain
- Less expensive
- Tranexamic acid has unproven addictive benefit when used with other local hemostatic measures including suturing
Managing bleeding
What is the procedure for patients to use aminocaproic acid solution?
Just before procedure: Hold 10 mL of aminocaproic acid solution for two minutes in affected area
After procedure: Repeat every one to two hours until solution is gone
Important to hold solution rather than swish (to avoid disturbing clot)
Is NSAID usage advised to be continued or stopped prior to procedure?
It is advised to stop NSAID usage - they have antiplatelet effects that are reversible
Stopping NSAIDS
To ensure absence of antiplatelet effect, when should NSAIDs be discontinued before the procedure?
NSAIDs should be discontinued five half-lives before the procedure (ranging from one day to ten days before procedure)
What are some of the conclusions of the article (part 1)?
- Should heparins, cilostazol, or dabigatran be stopped prior to procedure?
- Before a procedure, it is important to check what?
- What type of drugs SHOULD be discontinued?
They should be assumed necessary and should not be stopped.
It is important to check their INR.
Discontinue any unneeded antiplatelet agents (NSAIDS).
What are some of the conclusions of the article (part 2)?
- What type of drug should not be prescribed?
- What type of patients should be considered for inpatient management?
Antibiotics that increase warfarin effect should not be prescribed (erythromycin, clarithromycin, metronidazole)
Patients at high risk of thromboembolism requiring major oral surgery and patients taking antiplatelet combinations.
