Anticoagulants

Julene Funk
 Bleeding

When to consult?

Continue, Discontinue? Thromboembolism

When to resume?
Aspirin

• Irreversible inhibitor of
plt aggregation
• 10% of plt replaced
daily
• Hemostasis normalized
if 20% of plt
P2Y12 inhibitors
Plavix, Effient

Why is dual anti-platelet therapy initiated?

1. Acute setting MI
• Given for 3-6 months+
2. Stenting
• Bare metal: 6 weeks of dual therapy
• Drug eluting: 12 months of dual therapy
3. CVD/Stroke patient who is allergic or can
not tolerate ASA
What to do if my patient is on dual anti-platelet
therapy?
• Ask why they are on dual therapy? Or why are they on Plavix?
 Do you need to delay elective treatment? Recent MI, Stenting?
 Dual therapy increases risk of bleeding > X2 then ASA alone

• Minor surgery: Do not stop Plavix

• Major surgery: Consult PCP
• Stop Plavix: 5 days prior to surgery
• Stop prasugrel (Effient): 7 days prior to surgery
• Newer agent has higher chance of hemorrhage
 Xa Inhibitors
• Apixaban (Eliquis) BID
• Rivaroxaban (Xarelto) Qday

Direct Oral • Edoxaban (Lixiana) Qday

”anti-Xa” can be monitored
Anticoagulants:
DOACs
Thrombin Inhibitors
• Dabigatran (Pradaxa) BID
aPTT or ecarin clotting time can be
monitored
Indications of DOACs
1. Treatment or prophylaxis of DVT/PE
2. Prevention of stroke
• Non-valvular atrial fibrillation
3. Prophylaxis of VTE in orthopedics and hospitalized patients
4. Management of acute coronary syndrome
Advantages of DOACs over Warfarin
1. Predictable pharmacodynamics
o Less risk of bleeding then warfarin – metanalysis 2015 w/ > 100,000 patients
o No need for constant monitoring

2. Quick onset, quick off set

o No need for bridging

3. Decreased interactions with medication and foods

ARISTOTLE trial: showed that apixaban was superior to warfarin and had
better safety margin
DOACS Considerations
1. No Reversal!
 Reversal Xa: Andexanet alfa
 Reversal Praxbind ® (idarucizumab) 

2. Renally cleared
 Eliquis 25%
 Xeralto 70%
 Pradaxa 80%

3. Quick onset/offset: ~ ½ life < 12 hours

 Eliquis, Pradaxa: BID
 Xeralto: Qday CKD Stage Calculator
Study: Postoperative bleeding risk of
DOACs?
• X3 times postoperative risk of bleeding in OMFS procedures in comparison to healthy patients:
o Xeralto had a higher risk then Pradaxa for bleeding
o Eliquis was not included in the study due to limited data

• Studies varied in patient instructions:

o No change, procedure done 6 hours after last dose, hold 4 hours after procedure
o Skip morning dose, restart 4 hours after surgery
o Stop the night before, restart 1 day after surgery
o Stop 24 hours before
o Stop 48 hours before
Should I ask cardiologist to stop DOACS?
1. Assess your patient’s thromboembolism vs
bleeding risk:
o CHADS2 score? > 3 = high risk
o When DVT/PE/Stroke? < 3-6 months = high risk
o Comorbidities?

2. Is my procedure low-medium-high risk?

3. Probably not going to alter DOACS for clinic

procedures…
 1. Test out with one tooth first!
• Don’t jump into full mouth extraction

2. Understand short half life and frequency

• Xarelto: Qday

General • Eliquis/Pradaxa: BID

• Medium risk clinic surgery & patient with low risk of

Management of thromboembolism? Consider holding 24 hr or night before and

restarting >6-12 hours after procedure

DOAC Patients
3. Morning/early afternoon appointment! & no Friday appointments!

4. Local hemostatic measures always!!

5. High risk procedures: consult PCP, normal to stop 48 hours pre-op and
24 hours post op
• Patient with renal dysfunction may need longer times (3-5 days)
 Warfarin
• Vitamin K dependent • INR Goals: 2-3.5
factors
o II, VII, X, IX, C, S
o Long ½ life
o Initial 3 days:
Hypercoagulable
Why is Warfarin still used over DOACs?

1. Mechanical or tissue heart valve

2. Obesity
3. Renal Dysfunction
OMFS Clinical
North America Guidelines
 • INR 2.2 treated normally
• INR 2.2 – 4
• 5% TXA irrigate in socket
Study: Post- • Gel foam w/ sutures

op Bleeding • Gauze w/ 5% TXA for 30 minutes

• 5% TXA rinse QID for 2 minutes for 2
Following days
• Zero cases of post-op bleeding in < 2.2
Extractions
• 9 cases of post-op bleeding in group
with INR about > 2.2
o Still had bleeding despite TXA regimen
What is my patient’s thrombotic risk??
1. Afib: CHADS2 Score
• 0-2 low risk, No bridging needed
• 3-4 medium risk, Ask cardiology
• 5-6 high risk, requires bridge
2. Type heart valve: Mechanical (bileaflet) greater risk then bioprosthetic valves
o Mechanical valves are very high risk for VTE with INR goal 2.5-3.5
3. Time of DVT/PE/Stroke:
• High risk DVT/PE: 3-6 months
• High risk Stroke: 6 months
• Delay treatment if bleeding risk is high and you want to ask PCP to alter anti-coagulation
therapy
Case: Should my patient with Afib stop
DOACs or Warfarin?
“68 yo F w/ PMH of HTN, Afib, CHF on Xarelto 15 mg qday and a
creatinine clearance of 35 coming in for two molar dental extractions”?

Bleeding

Thromboembolism
Stroke Risk • CHADS2 (MDCALC CHADS2)
in Afib: o CHF History?
o HTN?
CHADS2 o > 75 years old
o DM
o Previous stroke or TIA

• CHADS2 < 3: low risk 

consider holding/delaying DOACs
• CHADS2 4-5: high risk
What is my patient’s bleeding risk?
1. Is patient above or at goal INR?
o Is INR high then therapeutic target?  send patient for evaluation by PCP to
normalize
2. Low-Medium-High risk procedure?
3. Platelet count < 150,000?
4. Any comorbidities?
o Uncontrolled Diabetes (plt dysfunction, quantitative vs qualitative)
o Liver function
o History of bleeding
Warfarin
Reversal
Vitamin K:
o Long onset time > 24 hr
o Only used if INR > 10, need for INR reversal for major surgery, or significant bleeding

PCC : 4 factors II, VII, IX, X

o INR > 2, acute bleeding is occurring
o Lower risk of adverse events the FPP which has all coagulation factors other then platelets
Warfarin & Antibiotics
• Commonly used OMFS antibiotics (Amoxicillin, Augmentin,
levofloxacin, metronidazole) all increase the anticoagulation
activity of Warfarin
Quick note about in patients
Heparin UFH & LMWH
• UFH: very short ½ life!
• DVT prophylaxis (5000 U BID): no contraindication to surgery
• Therapeutic IV drip: stop 4 hours before procedure, restart 2 hours after
procedure

• LMWH: longer ½ life!

• Prophylaxis: stop 12 hrs before procedure, restart 4-24 hr
• Therapeutic: stop 24 hrs before, restart 4-24 hr depending on bleeding risk
References
• Yoshikawa H, Yoshida M, Yasaka M, Yoshida H, Murasato Y, Fukunaga D, Shintani A, Okada Y. Safety of
tooth extraction in patients receiving direct oral anticoagulant treatment versus warfarin: a prospective
observation study. Int J Oral Maxillofac Surg. 2019 Aug;48(8):1102-1108. doi: 10.1016/j.ijom.2019.01.013.
Epub 2019 Feb 8. PMID: 30745243.
• Febbo, Anthony et al. Postoperative Bleeding Following Dental Extractions in Patients Anticoagulated With
Warfarin. Journal of Oral and Maxillofacial Surgery, Volume 74, Issue 8, 1518 – 1523
• Yoshikawa, H. et al. Safety of tooth extraction in patients receiving direct oral anticoagulant treatment
versus warfarin: a prospective observation study. International Journal of Oral and Maxillofacial Surgery,
Volume 48, Issue 8, 1102 – 1108.
• Steed, M. Swanson M. Warfarin and Newer Agents: What the Oral surgeon Needs to Know. Oral
Maxillofacial Surg Clin N Am 28 (2016) 515–521 http://dx.doi.org/10.1016/j.coms.2016.06.011
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