Background
Discussion
Dabigatran etexilate (Pradaxa®)
Perioperative bleeding associated to dabigatran etexilate
Perioperative thromboembolic risk associated to dabigatran etexilate
Dental consideration for patients taking dabigatran
Cretinine clearance (ml/min) | Time of discontinuation before surgery for standard risk of bleeding | Time of discontinuation before surgery for high risk of bleedinga |
---|---|---|
>80 | 24 h | 2–4 days |
>50 to ≤ 80 | 24 h | 2–4 days |
>30 to ≤ 50 | ≥48 h | 4 days |
≤30b | 2–5 days | 5 days |
Rivaroxaban (Xarelto®)
Perioperative bleeding associated to rivaroxaban
Perioperative thromboembolic risk associated to rivaroxaban
Dental consideration for patients taking rivaroxaban
Apixaban (Eliquis®)
Perioperative Bleeding associated to apixaban
Perioperative thromboembolic risk associated to apixaban
Dental considerations for patients taking apixaban
Final considerations
NOAs | Class | Indications | Dosage | Time to peak plasma concentration | Half life | Routes of elimination | Monitoring of coagulation |
---|---|---|---|---|---|---|---|
Dabigatran etexilate | Direct thrombin inhibitor | Prevention of cerebrovascular complications in non-valvular atrial fibrillation; hip and knee replacement surgery; venous thromboembolism prophylaxis and management | 110 mg- 150 mg twice daily | 2–4 h | 12–14 h; 14–17 h in elderly; 15–18 h in moderate renal impairment; up to 28 h in advanced renal impairment | 80 % renal, 20 % hepatic | Not needed |
Rivaroxaban | Direct inhibitor of factor Xa | Prevention of cerebrovascular complications in non-valvular atrial fibrillation; venous thromboembolism prophylaxis and management | 20 mg daily | 2.5–4 h | 5–10 h; 12–13 h in patients > 75 years | 66 % renal, 28 % in feces | Not needed |
Apixaban | Direct inhibitor of factor Xa | Prevention of cerebrovascular complications in non-valvular atrial fibrillation; venous thromboembolism prophylaxis and management | 5 mg twice daily | 1–3 h | 10–14 h | 25 % renal, 55 % intestinal, remnant hepatic | Not needed |
Author | Type of NOA | Minor surgical procedures (low-medium risk)a | Major surgical procedures and/or co-morbidities (high risk)b |
---|---|---|---|
Firriolo FJ and Hupp WS, 2012 [1] | Dabigatran | For dental procedure that involve bleeding: do not discontinue the daily dose in patient with normal renal function and without other risk for impaired haemostasis | For oral and maxillofacial surgical procedures with possible complications for excessive bleeding and/or impaired haemostasis: discontinue dabigatran ≥ 24 h before surgery or longer depending on renal impairment and bleeding risk (Table 1). Restart the drug at least 24 h postoperatively. |
Rivaroxaban | For dental procedure that involve bleeding: do not discontinue the daily dose in patient with normal renal function and without other risk for impaired haemostasis | For oral and maxillofacial surgical procedures with possible complications for excessive bleeding and/or impaired haemostasis: discontinue rivaroxaban ≥ 24 h before surgery or longer depending on renal impairment and bleeding risk (Table 1). Restart the drug at least 24 h postoperatively. | |
Davis C et al., 2013 [12] | Dabigatran | Perform surgery as long as possible after last dose Use local haemostatic measures | Discontinue 2–3 half –lives before surgery Adjust time of discontinuation for renal impairment |
Hong CH and Islam I, 2013 [36] | Dabigatran, Rivaroxaban, Apixaban | Do not change administration Use local haemostatic measures | Suspend administration 24 h before surgery and restart drugs after complete haemostasis is achieved at least after 24 h post-operatively |
Breik O et al., 2013 [37] | Dabigatran | Do not discontinue the drug Use local haemostatic measures (mechanical pressure, suturing an local haemostats) | In consultation with the patient’s physician, consider discontinuing the drug 24 h before procedure (or ≥ 48 h depending on degree of renal impairment) or changing to another anticoagulant preoperatively. Consider checking aPTT preoperatively Restart dabigatran 24–48 h after operation. |