Protocol in managing oral surgical patients taking dabigatran

Abstract

New anticoagulants are being introduced into the market. These drugs are orally administered, have predictable pharmacokinetics and dose response, do not require monitoring and have an acceptable safety profile when used appropriately, and so avoid many of the disadvantages and possible complications of warfarin and heparin. Dabigatran is the most widely used, and has been approved by the Therapeutic Goods Administration. The use of dabigatran will likely increase in the coming years, and so it is important for dentists to be aware of its mechanism of action, the possible complications, and how to reverse the bleeding if it occurs. This review discusses dabigatran and reports on our experience of five cases, and provides practical clinical advice on how to manage patients on dabigatran who require dental treatment, particularly extractions.Keywords: Anticoagulants, bleeding, dabigatran, extractions, oral surgery.Abbreviations and acronyms: aPTT = activated partial thromboplastin time; DVT = deep venous thrombosis; FFP = fresh frozen plasma; INR = International Normalized Ratio; LMWH = low molecular weight heparin; PT = prothrombin time; TGA = Therapeutic Goods Administration; TT = thrombin clotting time; UFH = unfractionated heparin.

Dental note: Treating patients on new anticoagulant drugs

“…To date, all published guidelines have been based purely on expert opinion and the consensus of multidisciplinary writing groups [4][5][6][7] or on clinical experience. 8 All guidelines recommend that dentists should take a cautious approach when performing invasive dental treatments for patients taking the new anticoagulants. Unlike warfarin, where the dose can be adjusted according to the INR, the new drugs are prescribed at fixed doses.…”

“…Referral to an oral and maxillofacial surgeon should be strongly considered for patients requiring extractions who have liver disease or impaired renal function, or complex medical histories, or who are also taking antiplatelet drugs. 8 A referral should also be considered when the required extractions are complex, extensive or have a high risk of postoperative bleeding.…”

Pharmacology: Dual therapy guidance

“…When restarting the NOACs, a desirable anticoagulant effect reaches its targeted level within a few hours following administration. 4 International dental guidelines for the new oral anticoagulants are based on a comparison of their bleeding risks with warfarin or low-molecular-weight heparins. Unfortunately, there are no evidence-based guidelines for the dental management of patients receiving these agents.…”

Gestion péri-opératoire des patients traités par antithrombotiques en chirurgie orale. Argumentaire

“…L'analyse exhaustive de la littérature n'a retrouvé que cinq sources d'information de faible niveau de preuve : un cas clinique [293], une série de cinq cas cliniques [47], trois revues systématiques de la littérature [77,101,105] et l'analyse rétrospective de l'essai RE-LY pour le dabigatran [164] et l'étude ROCKET-AF pour le rivaroxaban [238].…”

“…Breik et coll., 2014 [47] à partir d'une petite série de cas prospective (n = 5), conseillent de ne pas arrêter le dabigatran en cas d'extraction simple, le risque hémorragique pouvant être contrôlé par une hémostase locale. En revanche, les auteurs préconisent un arrêt du dabigatran en cas d'extractions multiples ou de procédure chirurgie orale complexe.…”