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Title Interruption in Use of the New Class of Direct Thrombin Inhibitors and Factor Xa Inhibitors is Not Indicated for the Anticoagulated Patient Undergoing Simple Dental Procedures
Clinical Question In a patient with atrial fibrillation taking Xarelto (rivaroxaban) or Pradaxa (dabigatran) how does the management of bleeding from dental procedures differ from patients on warfarin?
Clinical Bottom Line Disruption of Xarelto (rivaroxaban) or Pradaxa (dabigatran) regimen is not indicated when performing minor dental procedures that involve bleeding (ie, uncomplicated extractions). For invasive oral and maxillofacial surgical procedures, it is recommended to suspend rivaroxaban and dabigatran at least 24 hrs before surgery and to continue the regimen once post-operative bleeding is minimal. These recommendations are based on two narrative reviews.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 24120910van Diermen/2013Narrative Review
Key resultsFor patients on Xarelto (rivaroxaban) or Pradaxa (dabigatran) undergoing simple dental procedures in a general practitioners office the following guidelines were proposed: Interruption of rivaroxaban and dabigatran is not indicated. The only recommendation regarding their regimen is for the patient to not take their medication 1-3 hours prior to their appointment. Patient needs to be informed that bleeding is normal because their anticoagulation medication was not ceased.
#2) 22668425Firriolo/2012Narrative Review
Key resultsIf kidney function is normal, and there are no other risks for compromised hemostasis, then discontinuation of Xarelto and Pradaxa is not required for simple dental treatment that will cause bleeding. For oral and maxillofacial procedures where complications from bleeding are substantial, then discontinuation of Xarelto and Pradaxa for at least 24 hours before surgery is indicated. Discontinuation longer than 24 hours depends on the patients' renal function.
Evidence Search ("dental care"[MeSH Terms] OR ("dental"[All Fields] AND "care"[All Fields]) OR "dental care"[All Fields] OR ("dental"[All Fields] AND "procedures"[All Fields]) OR "dental procedures"[All Fields]) AND ("rivaroxaban"[Supplementary Concept] OR "rivaroxaban"[All Fields])
Comments on
The Evidence
Validity: The van Dierman article used the results of a literature search in the development of their guidelines, rating their findings based on the validity of the specific recommendations. Two guideline publications and 2 systematic reviews met their inclusion criteria. There needs to be more research into the topic as a whole to create guidelines that are reliable. The Firriolo article essentially based their guidelines on the pharmacological properties of rivaroxaban and dabigatran. These properties are a good way to judge how patients will handle certain treatments, but there needs to be RCT to better answer the clinical question. Perspective: Original research, such as a RCT, that explored the bleeding risk versus thrombotic events, would been preferable evidence if available. There needs to be more research into these drugs so the guidelines may be updated if any new information comes from these studies.
Applicability Rivaroxaban and dabigatran are new and emerging oral anticoagulants that are gaining popularity by physicians and patients. It is important to know how to manage patients on these medications, as they may eclipse warfarin as the drug of choice for oral anticoagulation. The half-life of these new oral anticoagulants is significantly shorter than warfarin, therefore complications from bleeding are reduced. A physician consult is recommended prior to suspension of the medication regimen prior to invasive surgery. Eliquis (apixaban) and Savaysa (edoxaban) are recently approved factor Xa inhibitors that have similar properties to Xarelto and Pradaxa but were not specifically discussed here.
Specialty/Discipline (General Dentistry) (Oral Surgery)
Keywords rivaroxaban, dabigatran, oral anticoagulants, xarelto, pradaxa
ID# 2828
Date of submission: 03/27/2015spacer
E-mail harrisonce@livemail.uthscsa.edu
Author Craig Harrison
Co-author(s) e-mail
Faculty mentor/Co-author Gregory K. Spackman, DDS, MBA
Faculty mentor/Co-author e-mail spackman@uthscsa.edu
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