Sir, I read with interest the recent letter by Professor Crispian Scully and Dr Mark Griffiths (New anticoagulants; BDJÂ 2012; 213: 96), advising dental surgeons on the likely rise in the prescription of the new anticoagulants dabigatran (a direct thrombin inhibitor) and rivaroxaban (a Factor Xa inhibitor) to eventually replace warfarin. In hospital practice we have certainly seen an increase in the number of referrals for patients taking these anticoagulants who require dental extractions.
It is likely that, as there is no need for routine coagulation monitoring of patients taking these drugs, dental surgeons may feel it is acceptable to advise patients to either continue taking them or to simply withdraw the drug for 24 hours, prior to invasive dental procedures. This is certainly not the advice of the manufacturers who state that 'surgical interventions may require temporary discontinuation of the drug' (Pradaxa) based on calculation of the creatinine clearance (the estimated half life of the drug increasing with poorer renal function). The length of time the drug should be withdrawn will depend on how effective renal function is, with normal function only requiring withdrawal for 24 hours before the dental procedure.
However, it would be dangerous to assume that all patients have normal renal function and manufacturers' recommendations for patients with creatinine clearances of between 30-50 ml/min1 (as opposed to above 80 ml/min in normal kidneys) advise that the drug is withdrawn for 2-3 days (>48 hours). Failure to do this means that levels could be high, resulting in postoperative haemorrhage, which is of particular concern as there is, as yet, no specific antidote or reversal agent for either of these drugs.
The consequence of this requirement will mean hospital referral if dental practitioners are not in a position to calculate renal function. This will also mean inevitable delay in treatment as this investigation will have to be carried out before treatment can take place, unlike most units who now use INR monitoring devices for patients taking warfarin that can provide virtually instant results.
I am rather concerned that over the last 30 years it became apparent that warfarin withdrawal was more of a risk than a benefit and that in future we may achieve the same result with the new anticoagulants.
References
Boehringer Ingelheim. Pradaxa Advice Sheet. July 2012.
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Davies, R. Increase in referrals. Br Dent J 213, 375–376 (2012). https://doi.org/10.1038/sj.bdj.2012.936
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DOI: https://doi.org/10.1038/sj.bdj.2012.936
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