Direct oral anticoagulants: A retrospective study of bleeding, behavior, and documentation

Abstract

Objective: To examine the effects of direct oral anticoagulants (DOACs) on bleeding complications following dental surgeries. Subjects and Methods:This 6-year retrospective study collected data from records of patients undergoing oral surgical procedures within a university setting. An electronic health record database was searched using current procedural terminology codes for oral surgical procedures. Information regarding patient, procedural factors, and postoperative complications were extracted. Data were analyzed by Fisher's exact test. Results:Of patients who had a procedural code associated with oral surgery, only 0.11% (12/11,320) took a DOAC. Twelve patients (10 males, age ranging from 44 to 90 years) underwent 17 surgeries by nine different practitioners involving 98 extractions, 14 alveoloplasties, two tuberosity reductions, and two tori removals. In nine cases, the DOAC was discontinued a mean of 52.5 hrs prior to surgery (range 12-120 hrs). Bleeding complications were not reported for patients whose drug was discontinued or continued. Documentation of drug continuation/discontinuation was poor. Conclusions:Bleeding was not observed with direct oral anticoagulation use in this oral surgery cohort. Drug discontinuation/continuation was not a factor in bleeding outcomes, and direct oral anticoagulation interruption was variable and poorly documented. K E Y W O R D Santicoagulants, bleeding, oral surgery, tooth extraction | INTRODUCTIONSince 2010, four direct oral anticoagulant (DOAC) drugs (ie, dabigatran, rivaroxaban, apixaban, and edoxaban) have been approved by the Food and Drug Administration. These drugs antagonize specific coagulation proteins (ie, Factor Xa and thrombin), which contribute to their pharmacological utility in preventing blood clots and strokes in patients who have atrial fibrillation. A main complication of DOAC use is bleeding. Current data indicate that DOACs demonstrate similar gastrointestinal bleeding rates (Spencer & Amerena, 2015) and lower major extra-cranial bleeding rates compared with warfarin (Connolly et al., 2009;Lee, 2016). The relationship of DOACs with dental procedure-related perioperative and postoperative bleeding is less well defined.At present, there are a limited number of clinical studies that have examined the use of DOACs and bleeding in association with invasive dental procedures. The two largest studies, the RE-LY and ARISTOTLE, reported on bleeding and dental procedures associated with dabigatran (n = 459) and apixaban (n = 1,435), respectively (Garcia et al., 2014;Healey et al., 2012). These studies while valuable do not specify the invasiveness and type of dental procedures performed, whether the DOAC was discontinued before the procedure and the relationship 244 | MILLER and MILLER of these factors to the frequency of major and minor bleeding. As a result, we depend on expert opinions (Albaladejo et al., 2017;Elad, Marshall, Meyerowitz, & Connolly, 2016;Firriolo & Hupp, 2012;Little, 2012;van Ryn et al., 2010) and smaller clinical studies to provide...

World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta‐analysis

“…None of the included studies was a randomized controlled trial (RCT). Nine articles were prospective case–control studies (Andrade et al., ; Berton et al., ; Caliskan, Tükel, Benlidayi, & Deniz, ; Clemm et al., ; Gómez‐Moreno et al., , ; Mauprivez et al., ; Miclotte et al., ; Miranda et al., ), four were retrospective case–control studies (Hanken et al., ; Kwak et al., ; Lababidi et al., ; Yagyuu et al., ), and five studies were retrospective (Johnston, ; Miller & Miller, ; Morimoto, Yokoe, Imai, Sugihara, & Futatsuki, ; Zeevi et al., ) and prospective (Patel et al., ) observational studies, reporting data from medical records. Three studies were case‐series (Abayon, Kolokythas, Siu, & Elad, ; Breik, Cheng, Sambrook, & Goss, ; Hassona, Malamos, Shaqman, Baqain, & Scully, ).…”

“…Although 21 studies were included in the review, only six studies (Johnston, ; Kwak et al., ; Lababidi et al., ; Miller & Miller, ; Patel et al., ; Zeevi et al., ) and two case‐series studies (Breik et al., and Hassona et al., ) reported on a direct comparison between these two groups of patients. The remaining 13 articles analyzed bleeding events in patients who had all discontinued DOAC therapy before surgery (Abayon et al., ; Gómez‐Moreno et al., ; Miclotte et al., ) or who continued it unchanged (Andrade et al., ; Berton et al., ; Caliskan et al., ; Clemm et al., ; Gómez‐Moreno et al., ; Hanken et al., ; Mauprivez et al., ; Miranda et al., ; Morimoto et al., ; Yagyuu et al., ).…”

“…None of the studies reported thromboembolic events. In particular, six studies stated specifically that no thromboembolic complications were recorded after invasive oral procedures (Clemm et al., ; Johnston, ; Mauprivez et al., ; Miller & Miller, ; Miranda et al., ; Patel et al., ).…”

“…Of the six studies, one study was assessed as good quality, four were evaluated as fair quality, and one of poor quality (Table ). Risk of bias of the 21 studies was assessed using the Newcastle‐Ottawa scale: two studies received a low risk of bias score (seven stars, Miller & Miller, ; Zeevi et al., ), 16 studies received a high risk of bias score (six stars, Andrade et al., ; Berton et al., ; Caliskan et al., ; Clemm et al., ; Gómez‐Moreno et al., , ; Hanken et al., ; Kwak et al., ; Lababidi et al., ; Mauprivez et al., ; Miclotte et al., ; Miranda et al., ; Morimoto et al., ; Patel et al., ; Yagyuu et al., and five stars, Johnston, ), and three case‐series received a very high risk of bias score (one star, Abayon et al., ; Breik et al., ; Hassona et al., ; Table ).…”

Neue orale Antikoagulanzien

“…In der Regel können diese Blutungen durch lokale Maßnahmen gestoppt werden [24]. Eine retrospektive Studie von Miller und Miller zeigt keine Unterschiede der Blutungen nach zahnärztlichen Eingriffen unabhängig, ob die Gabe der neuen oralen Antikoagulanzien unterbrochen wurde oder nicht [25]. Wahl et al vertreten die Ansicht, dass die Gabe von Antikogulanzien wegen zahnärztlicher Eingriffe nicht unterbrochen werden soll, weil sich sonst das Risiko für Thromboembolien erhöht [26].…”