9 / 40
Oral Anticoagulants
7
nmdental.org
O
ver the past several years, the FDA has approved some
new oral anticoagulant medications that provide an
alternative regimen for traditional Warfarin patients.
This article will review those medications and how I manage
surgery in an office setting.
Pradaxa (dabigatran etexilate)
was approved
by the FDA in 2010. It is a direct thrombin inhibitor indi-
cated to reduce the risk of stroke and systemic embolism in
patients with non-valvular a trial fibrillation; and for the treat-
ment and reduction of risk of deep vein thrombosis and pul-
monary embolism. Pradaxa is taken twice daily and does not
require INR monitoring (a major convenience for patients).
Dental Management:
Pradaxa has a half life of 13 hrs
and is around 90% eliminated in 24 hrs in patients with nor-
mal renal function. Minor surgical procedures can usually be
performed after this amount of time has passed. In patients
with impaired renal function, two or more days of holiday is
recommended. As with any modification of medication for
surgery, please consult and coordinate with the patients treat-
ing physician prior to any planned surgical procedure.
Xatelto (rivatoxaban)
was approved buy the FDA
in 2011. It is a factor Xa inhibitor indicated for the prophy-
laxis of deep vein thrombosis (DVT) in patients undergoing
knee or hip replacement surgery, to reduce the risk of stroke
in people who have abnormal heart rhythm (non-valvular atri-
al fibrillation) and to treat and reduce the risk of deep vein
thrombosis (DVT) or pulmonary embolism (PE). Xarelto is
taken once daily and does not require INR monitoring.
Dental Management:
Xarelto has a half life of 5–9 hrs
in patients with normal renal function. Similar to Pradaxa,
discontinuation is recommended at least 24 hrs prior to mi-
nor surgical procedures.
Eliquis (apixaban)
was approved by the FDA in
2012. It is a factor Xa inhibitor anticoagulant indicated to
reduce the risk of stroke and systemic embolism in patients
with nonvalvular atrial fibrillation, and for the prophylaxis of
deep vein thrombosis (DVT) in patients who have undergone
hip or knee replacement surgery. Eliquis is taken twice daily
and does not require INA monitoring.
Dental Management:
Eliquis has a half life of approxi-
mately 12 hrs. As with the other two medications above, dis-
continuation at least 24 hrs prior to minor surgical procedures
in patients with normal renal function should be adequate.
In my practice, I perform many extensive dent-alveolar proce-
dures. One of my concerns when discontinuing anticoagula-
tion is the increased risk of a thrombotic event in the office or
peri-operative period. I would prefer high risk patients to have
some degree of anticoagulation when they are treated in my
office. Many times, excessive bleeding can be controlled with
local measures (i.e. gel-foam, surgical). I have had good suc-
cess with high risk patients in switching their anticoagulant
therapy to a daily baby aspirin (81 mg) one week prior to their
scheduled surgery. This provides a manageable level of anti-
coagulation for larger procedures. Of course, this is discussed
with their treating physician prior to surgery.
By Eric Tuggle, DDS—Sandia Oral Surgery
Update on New Oral
Anticoagulants (NOAC's)
and Management in the
Surgical Dental Practice