dental management in patients receiving anticoagulation or antiplatelet treatment
DESCRIPTION
Dental management in patients receiving anticoagulation or antiplatelet treatmentTRANSCRIPT
DENTAL DENTAL MANAGEMENT IN MANAGEMENT IN
PATIENTS RECEIVING PATIENTS RECEIVING ANTICOAGULATION ANTICOAGULATION OR ANTIPLATELET OR ANTIPLATELET
TREATMENTTREATMENT
IS STOPPING OF THE THERAPY REALLY
REQUIRED IN MINOR DENTAL SURGERY ?
Piti Niyomsirivanich, MD.
CLINICAL SCENARIO
ผู้��ชาย 45 ปี Old CVA with AF with MR S/P MVR on warfarin 22 mg/week INR 3.0
จะถอนฟั�น ทำ�าไงดี� ? หย�ดียา warfarin ก่�อนไปีถอนฟั�น ไปีถอนฟั�นเลย
CLINICAL SCENARIO
ผู้��หญิ�ง 75 ปี Previous STEMI S/P PCI Drug Eluting Stent
เมื่ !อ 6 เดี อนก่�อน
ASA 81 mg/d + Clopidogrel 75 mg/d
จะไปีถอนฟั�น ทำ�าไงดี� หย�ดียา ASA + Clopidogrel ก่�อนไปีถอนฟั�น หย�ดียา ASA ก่�อนไปีถอนฟั�น หย�ดียา Clopidogrel ก่�อนไปีถอนฟั�น ไปีถอนฟั�นไดี�เลย
TUTORIAL IN ORAL ANTITHROMBOTIC THERAPY
ANTITHROMBOTIC DRUGS CATEGORIZED BY PHARMACODYNAMICS
Anti thrombotic drug categories
Generic names and subgroup
Antiplatelet agents COX-1 inhibitor Aspirin
ADP receptor inhibitor: Clopidogrel ,Prasugrel ,Ticlopidine ,Ticagrelor
Gp IIb/IIIa inhibitor Abciximab ,Eptifibatide , Triofiban
Phosphodiesterase inhibitor Cilostazol , Dipyridamole
Vitamin K antagonist Warfarin , Coumarin , Dicoumarol , Phenprocoumon , Acenocoumarol
Factor Xa inhibitor Enoxaparin (SC), Fundaparinux (SC), rivaroxaban(SC)
Direct thrombin inhibitor dabigatran
Thrombolytic drugs tPAAlteplase , Tenecteplase , Reteplase , Streptokinase , UrokinaseAdapted from Cochrane Database Syst. Rev,CD 001820.
OVERVIEW OF CLOT FORMATION
injury
TF ThrombinCoagulation cascade
Collagen vWF
ADP
Thromboxane A2
P2Y12
PAR-1
GP IIb/IIIa
Fibrin platelet aggregation
Xa/Va prothrominase complex
OVERVIEW OF CLOT FORMATION
injury
TF ThrombinCoagulation cascade
Collagen vWF
ADP
Thromboxane A2
P2Y12
PAR-1
GP Iib/IIIa
Fibrin platelet aggregation
Xa/Va prothrominase complex
CONCEPTS ON EARLY COAGULATION CASCADE
Intrinsic pathway extrinsic pathway
TF/VIIa
XI XIa
IX IXa
XaX X
XII,HMK , PK
Prothrombin(II) Thrombin
Fibinogen(I) Fibrin
PL ,VIIIa Ca PL, Ca
PL ,Va Ca
Adapted from Thromb Haemost 85(6):958-65
CONCEPTS ON EARLY COAGULATION CASCADE
Intrinsic pathway extrinsic pathway
TF/VIIa
XI XIa
IX IXa
XaX X
XII,HMK , PK
Prothrombin(II) Thrombin
Fibinogen(I) Fibrin
VKA e.g. warfarin
Inh. II , VII ,IX ,X
PL ,VIIIa Ca PL, Ca
PL ,Va Ca
Adapted from Thromb Haemost 85(6):958-65
CONCEPTS ON EARLY COAGULATION CASCADE
Intrinsic pathway extrinsic pathway
XI XIa
Xa
XII,HMK , PK
Fibinogen(I) Fibrin
Factor Xa inhibitor : Enoxaparin ,
Fundaparinux
PL ,VIIIa Ca PL, Ca
PL ,Va Ca
TF/VIIaIX IXa
Prothrombin(II) Thrombin
Adapted from Thromb Haemost 85(6):958-65
X X
CONCEPTS ON EARLY COAGULATION CASCADE
Intrinsic pathway extrinsic pathway
XI XIa
XII,HMK , PK
Fibinogen(I) Fibrin
Direct thrombin inhibitor :
dabigatran
PL ,VIIIa Ca PL, Ca
PL ,Va Ca
TF/VIIaIX IXa
Prothrombin(II) Thrombin
XaX X
Adapted from Thromb Haemost 85(6):958-65
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
Initiation
TF –bearing celle.g. fibroblast TF
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
Initiation
TF –bearing celle.g. fibroblast TF
VII
VIIa
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
Initiation
TF –bearing celle.g. fibroblast TF
VIIa
TF/VII complex
X
Xa
IX
IXa
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
Initiation
TF –bearing celle.g. fibroblast TF
VIIa
TF/VII complex
IXa
Xa/Va complex
VaXa
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
Amplification
TF –bearing celle.g. fibroblast TF
VIIa
TF/VII complexVaXa
IXa
Xa/Va complex
prothrombin
Thrombin
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
AmplificationTF –
bearing celle.g.
fibroblast
TF
VIIa
Va
Xa
IXa
Thrombin
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
AmplificationTF –
bearing celle.g.
fibroblast
TF
VIIa
Va
Xa
Thrombin
Platelet Activation
VaV
vWF/VIII
VIIIa
IXa
IX
PAR1,PAR4
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
Thromboxane A2 synthesis
CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL
PropagationTF –
bearing celle.g.
fibroblast
TF
VIIa
Va
Xa
Activated Platelet
Va
VIIIa IXa
Intrinsic tenase
X Xa
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
CONCEPS ON THE NEW, CELL-BASED COAGULATION MODEL
PropagationTF –
bearing celle.g.
fibroblast
TF
VIIa
Va
Xa
Activated Platelet
Va
VIIIa IXa
Intrinsic tenase
XaVa/Xa complex(Prothrombinase)
Fibrinogen Fibrin
Prothrombin Thrombin
Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8
PRE-OPERATIVE EVALUATION FOR ANTICOAGULANTS
Bleeding Risk Procedure
Versus
Risk of thromboembolic events
Whether to off anticoagulants ?
PATIENT VERSUS SURGICAL RISK FACTORS
Patient Risk Factors
Prior thromboembolism ?
Mechanical valve ?
AF ?
Surgical Risk Factors
Procedure type ? Quantify Risk of
bleeding ?
Quantify Risk of thromboembolism ?
RISK OF THROMBOEMBOLISM
Michael et al. After discontinue OAT in 169 patients 22% thromboembolic event 7% died
Tulloch and Wright et al. Case Report Discontinue OAT for 8 days before oral surgery Post operative day 2 CVA Post operative day 4 branchial artery emboli
Br Heart J 1970;32:359-364Circulation 1954;9:823-834
RISK OF THROMBOEMBOLISM
Wahl et al. Review > 2400 cases 950 cases continued oral antithrombotic
12 cases experienced post-operative bleeding Which controlled by local measures
Incidence of thromboembolic complication was about 1%
Small but outcome serious !!!
Arch Intern Med 1998;158:1610-1616
RISK OF HEMORRHAGE
Cambell et al. Randomized controlled trial Continue OAT versus withdrawn OAT No significant difference in total blood loss
Madrid and Sanz Systemic review Continue OAT with INR 2-4 and discontinue OAT No significant in post operative hemorrhage
J oral Maxillofac Surg 2000;58:131-135Clin Oral Implants Res 2009;20 Suppl 4:96-106
MEANING OF INR VALUE
Most anticoagulation therapyINR 2.0 - 3.0
Few INR 3.0 - 4.0
Blinder et al. INR value did not significantly influence the
incident of perioperative bleeding (INR 2.0 -4.0)
INR 2.0-4.0 post operative hemorrhage can not be so serious
Int J Oral Maxillo Surg 2008;66:51-57
CONCLUSION
ThromboembolisThromboembolism Riskm Risk
Bleeding Risk
Local control
Small but outcome serious !!! Arch Intern Med 1998;158:1610-1616
CHEST 2012; 141:326-350S
CLINICAL SCENARIO
ผู้��ชาย 45 ปี Old CVA with AF with MR S/P MVR on warfarin 22 mg/week INR 3.0
จะถอนฟั�น ทำ�าไงดี� ? หย�ดียา warfarin ก่�อนไปีถอนฟั�น ไปีถอนฟั�นเลย
OVERVIEW OF CLOT FORMATION
injury
TF ThrombinCoagulation cascade
Collagen vWF
ADP
Thromboxane A2
P2Y12
PPAR-1
GP Iib/IIIa
Fibrin platelet aggregation
Xa/Va prothrominase complex
ANTIPLATELET
promote
vWFvWF
ASPIRIN ARACHIDONIC ACID METABOLISM
Phospholipid-Arachidonic acid
Phospholipases
Arachidonic acid
Prostaglandin G2
Prostaglandin H2
Tissue Specific Isomerases
COX1
HOX
Arachidonic acid
Prostaglandin G2
Prostaglandin H2
COX2
HOX
Thromboxane A2(Promote Thrombosis)
Prostaglandin D2 Prostaglandin E2 Prostaglandin F2aProstacyclin(inhibit Plt aggregation)
Low dose ASA High dose ASA(Inflammatory dose)
Higher dose block
Adapted from: CHEST 2012; 141(2) (Suppl) : e89S-e119S
Platelets & vascular endothelial cells
Dipyridamole. effects of dipyridamole on NO/cGMP and prostaglandin/cAMP signal transduction in human
platelets.
Adapted from :Aktas B et al. Stroke. 2003;34:764-769
Copyright © American Heart Association, Inc. All rights reserved.
Platelet aggregation Platelet aggregation
DIPYRIDAMOLE.PROMOTE PROSTACYCLIN
promote
CILOSTAZOL PHOSPHODIESTERASE III INHIBITORS
Eur Heart J (2008) 29 (18): 2202-2211.
Vasodilatory stimulating phosphoprotein
THIENOPYRIDINESTICLOPIDINE ,CLOPIDOGREL , PRASUGREL
Eur Heart J (2008) 29 (18): 2202-2211.
ANTIPLATELET AND ORAL SURGERY
Ardekian et al. 39 patients taking ASA 100 mg
19 continued20 stopped
Bleeding time 3.1 min versus 1.8 min (p=0.004)
None of them had prolong bleeding time >10 min
No patient experienced uncontrolled bleeding Antiplatelet should not be discontinued prior to
dental procedureJ Am Dent Assoc 131,331-335
DUAL ANTIPLATELET OR SINGLE ANTIPLATELET?
Nepanas et al. Retrospective study 43 patients who were receiving single or dual
antiplatelet therapy
Twenty-nine patients (67 percent) were receiving dual antiplatelet therapy.
The authors found no differences between patients receiving single or dual antiplatelet therapy for all variables.
J Am Dent Assoc. 2009 Jun;140(6):690-5
COMPLICATION RATES FROM DISCONTINUATION OF ANTIPLATELETE < 6 WKS AFTER PCI W/WO STENT
CHEST 2012; 141:326-350S
CLINICAL SCENARIO
ผู้��หญิ�ง 75 ปี Previous STEMI S/P PCI Drug Eluting Stent
เมื่ !อ 6 เดี อนก่�อน
ASA 81 mg/d + Clopidogrel 75 mg/d
จะไปีถอนฟั�น ทำ�าไงดี� หย�ดียา ASA + Clopidogrel ก่�อนไปีถอนฟั�น หย�ดียา ASA ก่�อนไปีถอนฟั�น หย�ดียา Clopidogrel ก่�อนไปีถอนฟั�น ไปีถอนฟั�นไดี�เลย
CLINICAL SCENARIO
ผู้��หญิ�ง 75 ปี Previous STEMI S/P PCI Drug Eluting Stent
เมื่ !อ 6 เดี อนก่�อน
ASA 81 mg/d + Clopidogrel 75 mg/d
จะไปีถอนฟั�น ทำ�าไงดี� หย�ดียา ASA + Clopidogrel ก่�อนไปีถอนฟั�น หย�ดียา ASA ก่�อนไปีถอนฟั�น หย�ดียา Clopidogrel ก่�อนไปีถอนฟั�น ไปีถอนฟั�นไดี�เลย
LOCAL BLEEDING CONTROL
Local anesthesia with vasoconstrictor Local hemostatic material (bonewax ,surgicel) Local hemostatic agent (epinephrine solution )
Suture Pressure Dressing Peridontal pack application Tranexamic acid Mouth wash
Journal of Oral Science,Vol.49,No.4,253-258,2007
TAKE HOME MESSAGE Warfarin
ถ�า INR 2 - 4 ไมื่�ต้�องหย�ดี
ถ�า INR > 4 ไมื่�ต้�องผู้�า/ทำ�าฟั�นทำ�ก่ก่รณี�
Antiplatelets ASA , clopidogrel ,prasugrel , ticlopidine ,
cilostazole , Tegagrelor etc.
ไมื่�ต้�องหย�ดีทำ�ก่รณี� ไมื่�ว่�าจะ on ดี�ว่ย indication primary prevention , secondary prevention , S/P stent ก่&ต้ามื่ ทำ'(ง single หร อ dual antiplatelet
HIGH ALERT DON’T STOP OAT!!!
Warfarin Mechanical valve , Hypercoagulable state
Antiplatelet S/P w Stent [DES , BMS] within 1 years
สุ�ดีทำ�าย
หาก่ INR สุองถ*งสุ�!น' (น บ่�หย�ดีINR เก่�น 4 ให� ผู้�าไมื่�antiplatelet ไซร� อย�าไดี�
หย�ดีเลยบ่�หย�ดีOATไว่� จ'ก่ไดี�
ปีลอดีภั'ย
THANK YOU