Warfarin guidance Flashcards
Why can bleeding in the mouth be excessive?
- mouth is highly vascular
- saliva contains fibrinolytic agents
What is a clinically significant bleed defined as?
- continues beyond 12 hours
- causes patient to call/ return to dental practice/A&E
- results in the development of a large haematoma or ecchymosis within soft tissues
- requires blood transfusion
Bleeding complications carry the same risks as thromboembolic complications. True or false
False
When is it indicated for the dose of warfarin to be adjusted for a patient requiring dental surgical procedure?
INR >4
The risk of thromboembolic events following stopping warfarin for 2 days is between …
0.02 and 1%
What medical problems may affect coagulation and clotting?
- liver impairement and/or alcoholism
- renal failure
- thrombocytopenia, haemophilia or other disorder of haemostasis
- those currently receiving a course of cytotoxic medication
What should be the INR target for patients taking warfarin to manage a pulmonary embolus ?
(State the acceptable range)
2.5
(2.0-3.0)
What should be the INR target for patients taking warfarin to manage DVT ?
(State the acceptable range)
2.5
2.0-3.0
What should be the INR target for patients taking warfarin to manage atrial fibrillation ?
(State the acceptable range)
2.5
2.0-3.0
What should be the INR target for patients taking warfarin to manage antiphospholipid syndrome ?
(State the acceptable range)
3.5
3.0-4.0
What should be the INR target for patients taking warfarin to manage mechanical prosthetic heart valves ?
(State the acceptable range)
3.5
3.0-4.0
What should be the INR target for patients on warfarin at risk of experiencing recurrent embolism ?
(State the acceptable range)
3.5
3.0-4.0
What should be the INR target for patients at risk of recurrent embolusm no longer taking warfarin ?
(State the acceptable range)
2.5
2.0-3.0
When should INR be measured before a dental procedure?
ideally 24 hours before the procedure
for patients who have a stable INR, measuring it 72 hours before the procedure is acceptable
The INR is only valid for patients who have stable anticoagulant therapy. What is the implication of this?
this means that patients presenting with INR values much higher than their normal value (even if it is less than 4.0) should have their procedure postpones or referred back to clinician maintaining their anticoagulant therapy
What procedures can warfarin be continued safely
minor surgical procedures e.g.
* extraction of up to 3 teeth
* gingival surgery
* crown and bridge procedures
* dental scaling
* surgical removal of teeth
Why should scaling and root planing be restricted to a limited area for a patient on warfarin?
to assess whether or not the bleeding is problematic
What is the benefit to planning surgical procedures at the beginning of the day / earlier in the week for patients on anticoagulant therapy?
- earlier in the day allows more time to deal with immediate re-bleeding problems
- earlier in the week- allows delayed re-bleeding episodes occuring after 24-48 hours to be dealt with in the working week
Outline some POI for the management of the clot in the post operative period
- look after clot by resting while LA wears off and clot fully forms (2-3 hours)
- avoid rinsing mouth for 24 hours
- not to suck hard or disturb socket with tongue or foreign object
- avoid hot liquids and hard foods for the rest of the day
- avoid chewing on affected side until clear clot has formed
- if bleeding restarts apply pressure over socket using a folded clean handkerchief or gauze pad; place over socket and hold in place for 20 minutes
- pt should be aware of who to contact if they have excessive or prolonged bleeding
- advice on pain control should be provided
What is considered to be the safest analgesic for patients taking warfarin?
paracetamol
What analgesics are patients on warfarin advised not to take?
- aspirin
- other NSAIDs such as ibuprofen
State some options for analgesia that can be prescribed to a patient taking warfarin
- rofecoxib (COX-2 inhibitors) - risk of GI bleed lower
- dihydrocodeine- opioid analgesic with similar efficacy to codeine - no anti-inflammatory activity
Both amoxicillin (single 3g dose) and clindamycin taken as endocarditis prophylaxis do not produce a clinically relevant interaction. True or false
True
The anticoagulant effects of warfarin may be enhanced by prolonged regular use of paracetamol. True or false
True
Key words: prolonged, regular use
What are the potential effects of concurrent use of warfarin and aspirin ?
- increases likelihood of bleeding by 3-5 times
- increases bleeding time
- may damage lining of the stomach
What is the advise for use of NSAIDs such as diclofenac and ibuprofen in patients on anti-coagulant therapy?
avoid due to increased risk of GI bleeding
What is the advice for patients on Rofecoxib taking warfarin?
they should be closely monitored; in patients on chronic warfarin therapy, treatment with rofecoxib has been associated with increased INR
Risk of GI bleeding is still present but better than risk of GI bleeding with NSAIDs
What is the primary MOA of tranexamic acid?
blocks the binding of plasminogen and plasmin to fibrin
Therefore prevents fibrin clot dissolution
Anti-fibrinolytic agent
Tranexamic acid cannot be prescribed under what type of prescription?
FP10D
but it can be prescribed privately
Tranexamic acid is not in the DPF
How can a prescriber/ pharmacist obtain the unlicensed tranexamic acid mouthwash in order to fill a prescription?
- “special order” manufacturer
What is the shelf life of special order supplies of tranexamic acid?
1-3 months
What are the requirements for the labelling of dispensed medicinal products?
- name of product
- directions of use
- precautions relating to its use
- name of person whm medicine is to be administered
- date of dispensing
- name and address of dentist supplying the medicinal product
- words “keep out of reach of children” or words with a similar meaning
What method of local anaesthetic delivery should be avoided where possible?
regional nerve blocks
if not alternative is available then use an aspirating syringe
