Coagulation Cascade

Direct Oral Anti Coagulation

Direct Thrombin Inhibitors

• Dabigatran – Pradaxa
• Argatroban, Bivalirudin: have short half-lives and typically do not need reversal other than discontinuation
• Aripazine: potential antidote to direct thrombin inhibitors by binding directly to them

Warfarin

• Vitamin K can be administered in nonurgent situations
• FFP/Prothrombin complex concentrate: urgent reversal of warfarin

DOACs

• Apixaban, rivaroxaban: do not have clear reversal agents. Holding drug for 24h for nonurgent surgery is typically enough.
• Dabigatran: can be reversed with idarucizumab
• **andexanet alfa – reversal for factor Xa DOACs, direct thrombin inhibitors, LMWHs, and even fondaparinux

Coagulation & Kinin Pathways

Platelet Plug Formation

Thrombogenesis

• Formation of insoluble fibrin mesh.
• Aspirin irreversibly inhibits cyclooxygenase, thereby inhibiting TXA2 synthesis.
• Clopidogrel, prasugrel, and ticlopidine inhibit ADP-induced expression of GpIIb/IIIa via P2Y12 receptor.
• Abciximab, eptifibatide, and tirofiban inhibit GpIIb/IIIa directly.
• Ristocetin activates vWF to bind GpIb. Failure of aggregation with ristocetin assay occurs in von Willebrand disease and Bernard-Soulier syndrome.

• Apixaban – Eliquis
• Rivaroxaban – Xarelto
• Dabigatran – Pradaxa
• Lixiana – Edoxaban
• Enoxaparin – Lovenox

Oral Anticoagulant and Antiplatelet Medications and Dental Procedures

• Low Risk Procedure: administration of local anesthetic, simple restorations, supragingival scaling, and single tooth extraction
• Medium/High Risk Procedure: extractions of 2 to 4 teeth and local gingival surgery of 5 or fewer teeth
• Typical Patient: No need to discontinue medication; use local measures to control bleeding
• Patients with Higher Risk of Bleeding: Any suggested modification to the medication regimen prior to dental surgery should be done in consultation with and on advice of the patient’s physician
• https://www.ada.org/en/member-center/oral-health-topics/oral-anticoagulant-and-antiplatelet-medications-and-dental-procedures

Abixaban (Eliquis)

Curto A, Albaladejo A. Implications of apixaban for dental treatments. J Clin Exp Dent. 2016;8(5):e611-e614. Published 2016 Dec 1. doi:10.4317/jced.53004

• There is general agreement that in most cases, treatment regimens with older anticoagulants (e.g., warfarin) and antiplatelet agents (e.g., clopidogrel, ticlopidine, prasugrel, ticagrelor, and/or aspirin) should not be altered before dental procedures. The risks of stopping or reducing these medication regimens (i.e., thromboembolism, stroke, MI) far outweigh the consequences of prolonged bleeding, which can be controlled with local measures. In patients with comorbid medical conditions that can increase the risk of prolonged bleeding after dental treatment or who are receiving other therapy that can increase bleeding risk, dental practitioners may wish to consult the patient’s physician to determine whether care can safely be delivered in a primary care office. Any suggested modification to the medication regimen prior to dental surgery should be done in consultation and on advice of the patient’s physician.
• On the basis of limited evidence, general consensus appears to be that in most patients who are receiving the newer direct-acting oral anticoagulants (i.e., dabigatran, rivaroxaban, apixaban, or edoxaban) and undergoing dental interventions (in conjunction with usual local measures to control bleeding), no change to the anticoagulant regimen is required. In patients deemed to be at higher risk of bleeding (e.g., patients with comorbid conditions or undergoing more extensive procedures associated with higher bleeding risk), consideration may be given, in consultation with and on advice of the patient’s physician, to postponing the timing of the daily dose of the anticoagulant until after the procedure; timing the dental intervention as late as possible after last dose of anticoagulant; or temporarily interrupting drug therapy for 24 to 48 hours. Further research is needed to definitively establish periprocedural management strategies for these patients, especially those considered to be at higher risk of bleeding.