Anticoagulants and Oral Surgery
With the aging of the population, and their increased need for medications for cardiovascular and neurologic conditions, many older patients are on some form of anticoagulant therapy. You have probably heard these anticoagulant medications called “blood thinners”. A new class of medications called Direct Acting Oral Anticoagulants (DAOC’s) are being commonly prescribed. They are used to treat certain blood vessel, heart and lung conditions, including: atrial fibrillation (AFib), peripheral artery disease (PAD) and venous thromboembolism (VTE). Anticoagulants help prevent blood clots from forming in an artery, a vein or the heart, and may prevent existing clots from getting larger.
AFib patients are commonly on one or more of these medications because of their irregular heartbeats, which can cause blood clots that can travel to the brain, restricting the blood supply to the area and causing a stroke. About one in five people who have a stroke has AFib!
These medications include:
- Apixaban (Eliquis®)
- Dabigatran (Pradaxa®)
- Rivaroxaban (Xarelto®)
- Edoxaban (Savaysa™)
The traditional anticoagulant Warfarin (Coumadin) requires continual monitoring in the form of a blood test called an INR. It is necessary to keep the INR within a therapeutic range as determined by your physician. This can be difficult to do and can be affected by many factors including other medications, and dietary issues.
The DAOC’s do not require this type of continual monitoring and for this reason along with others, have become very popular. DOACs have been shown to be highly effective, require less monitoring, and may reduce the risk of brain bleed when taken for stroke prevention. They also work more quickly and clear the system faster than warfarin.
Because we in oral surgery see many patients on these medications, this issue has been studied extensively. There are several scientific articles in the literature now that state that it is safe to remove one or 2 teeth, or perform minor oral surgery such as a soft tissue biopsy, while patients are on the DAOC’s. However, you must read these articles closely, because it does not say that 100% of the people do well 100% of the time! In fact, most authors agree that 83% of the people will do well. That means that 17% of the population will have some form of postoperative bleeding after minor oral surgery if the anticoagulant medication is not stopped prior to surgery.
How do we manage this? Consultation with your physician will be required prior to surgery in most cases. Stopping an anticoagulant medication has side effects itself- such as an increased risk for stroke or heart attack. We must weigh the “risk-benefit” of stopping versus continuing these medications during minor oral surgery. Understand that, if you have postoperative bleeding while on these medications, surgical measures such as suturing and packing (which will be done at time of surgery) may be of little benefit because you are unable to form a clot. If you cannot form a clot, you cannot stop bleeding! Whether or not to stop your anticoagulant medication pre-surgically is not a simple decision. The decision involves many factors that must be considered carefully. If your prescribing physician deems the risk of stopping your anticoagulant medication to be minimal, then that is usually the safest course for surgical procedures (remember that 17% of people will have bleeding without holding the medication!). If your physician deems your risk of stopping the medication to be moderate or high, and the procedure is a minor one, then stopping the medication is usually not the best course of action. Ultimately, the decision whether or not to hold an anticoagulant medication for an oral surgical procedure will involve a combined decision between the surgeon and your prescribing physician.
This becomes a medical management issue and on occasion patients may have to be hospitalized or seen in the emergency room. Thankfully this is a rare phenomenon, however excessive bleeding is a risk for anyone on anticoagulants. The effects of warfarin usually can be reversed with vitamin K. One important concern of patients and physicians has been that there was no specific antidote for DOACs. This is no longer the case. In 2015 the FDA approved idarucizumab (Praxbind®) for reversal of dabigatran (Pradaxa®). On May 4th 2018, FDA approved andexanet alfa (AndexXa®) for the reversal of apixaban (Eliquis®) and rivaroxaban (Xarelto®). Ongoing studies are confirming its efficacy in reversing the other DOACs on the market betrixaban (BevyxXa®) and edoxaban (Savaysa®) as well as the low molecular weight heparin enoxaparin (Lovenox®) and fondaparinux (Arixtra®). Physicians can use prothrombin complex concentrate in emergency situations involving blood thinners that do not have a specific reversal agent yet approved by FDA. The good news is, these medications do a tremendous service to patients with cardiovascular, peripheral vascular, and neurologic issues. They save lives. Remember that any medication has side effects, and anticoagulants’ side effect (and intended effect!) is to prevent clot formation.
We will work closely with your physician to choose the best course of action for you if you are on one of these medications. Rest assured that our concern is for your health and safety and we want you to have a pleasant and positive experience.
If you have any questions regarding these medications or how we would manage your case, please feel free to consult with Dr. Stewart or Dr. Michael.
Texas Oral Surgery Group: LARRY R. STEWART, DDS, MS WAYNE A. MICHAEL, DDS, MD
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