Severe Enoral Bleeding with a Direct Oral Anticoagulant After Tooth Extraction and Heparin Bridging Treatment

Overview

Journal Case Rep Emerg Med

Specialty Emergency Medicine

Date 2019 Nov 30

PMID 31781415

Citations 4

Authors

Simone Ehrhard

John Patrik Burkhard

Aristomenis K Exadaktylos

Thomas C Sauter

Affiliations

Soon will be listed here.

Abstract

Background: The number of patients receiving direct oral anticoagulants (DOACs) is increasing, however, this treatment is associated with the risk of bleeding. More than 10 percent of patients on DOACs have to interrupt their anticoagulation for an invasive procedure every year. For this reason, the correct management of DOACs in the perioperative setting is mandatory.

Case Presentation: An 81-year-old male patient, with known impaired renal function, presented to our emergency department with a severe enoral bleeding after tooth extraction. The DOAC therapy-indicated by known atrial fibrillation-was interrupted perioperatively and bridged with Low Molecular Weight Heparin (LMWH). The acute bleeding was stopped by local surgery. The factors contributing to the bleeding complication were bridging of DOAC treatment, together with prolonged drug action in chronic kidney disease.

Conclusion: In order to decide whether it is necessary to stop DOAC medication for tooth extraction, it is important to carefully weigh up the individual risks of bleeding and thrombosis. If DOAC therapy is interrupted, bridging should be reserved for thromboembolic high-risk situations. Particular caution is required in patients with impaired kidney function, due to the risk of accumulation and prolonged anticoagulant effect of both DOACs and LMWH.

Citing Articles

Bleeding Complications in Relation to the International Normalized Ratio for Dental Extractions in Patients under Chronic Anticoagulant Therapy - An Evaluative Study.

Puia S, Hilber E, Garcia-Blanco M Ann Maxillofac Surg. 2023; 12(2):139-143.

PMID: 36874771 PMC: 9976852. DOI: 10.4103/ams.ams_113_22.

Risk factors for bleeding after dental extractions in patients receiving antithrombotic drugs - A case control study.

Huang J, Liu J, Shi H, Wu J, Liu J, Pan J J Dent Sci. 2022; 17(2):780-786.

PMID: 35756819 PMC: 9201513. DOI: 10.1016/j.jds.2021.10.005.

Randomized Clinical Trial Comparing Three Local Hemostatic Agents for Dental Extractions in Patients under Chronic Anticoagulant Therapy - A Comparative Study.

Puia S, Hilber E, Garcia-Blanco M Ann Maxillofac Surg. 2021; 10(2):292-296.

PMID: 33708570 PMC: 7943974. DOI: 10.4103/ams.ams_276_20.

Bleeding Complications in Anticoagulated and/or Antiplatelet-Treated Patients at the Dental Office: A Retrospective Study.

Martinez-Moreno E, Martinez-Lopez F, Rodriguez-Lozano F, Onate-Sanchez R Int J Environ Res Public Health. 2021; 18(4).

PMID: 33567762 PMC: 7915452. DOI: 10.3390/ijerph18041609.

References

Gage B, van Walraven C, Pearce L, Hart R, Koudstaal P, Boode B . Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation. 2004; 110(16):2287-92. DOI: 10.1161/01.CIR.0000145172.55640.93. View

Mauprivez C, Khonsari R, Razouk O, Goudot P, Lesclous P, Descroix V . Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016; 122(5):e146-e155. DOI: 10.1016/j.oooo.2016.06.003. View

Lip G, Frison L, Halperin J, Lane D . Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR,.... J Am Coll Cardiol. 2010; 57(2):173-80. DOI: 10.1016/j.jacc.2010.09.024. View

Muller M, Schlittler F, Schaller B, Nagler M, Exadaktylos A, Sauter T . Characteristics, treatment and outcome of bleeding after tooth extraction in patients on DOAC and phenprocoumon compared to non-anticoagulated patients-a retrospective study of emergency department consultations. Clin Oral Investig. 2018; 23(5):2273-2278. DOI: 10.1007/s00784-018-2676-7. View

Sherwood M, Douketis J, Patel M, Piccini J, Hellkamp A, Lokhnygina Y . Outcomes of temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: results from the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention.... Circulation. 2014; 129(18):1850-9. PMC: 4206548. DOI: 10.1161/CIRCULATIONAHA.113.005754. View

Tafur A, Douketis J . Perioperative anticoagulant management in patients with atrial fibrillation : practical implications of recent clinical trials. Pol Arch Med Wewn. 2015; 125(9):666-71. DOI: 10.20452/pamw.3049. View

Mar P, Familtsev D, Ezekowitz M, Lakkireddy D, Gopinathannair R . Periprocedural management of anticoagulation in patients taking novel oral anticoagulants: Review of the literature and recommendations for specific populations and procedures. Int J Cardiol. 2015; 202:578-85. DOI: 10.1016/j.ijcard.2015.09.035. View

Sumanth K, Prashanti E, Aggarwal H, Kumar P, Lingappa A, Muthu M . Interventions for treating post-extraction bleeding. Cochrane Database Syst Rev. 2016; (6):CD011930. DOI: 10.1002/14651858.CD011930.pub2. View

Testa S, Tripodi A, Legnani C, Pengo V, Abbate R, Dellanoce C . Plasma levels of direct oral anticoagulants in real life patients with atrial fibrillation: Results observed in four anticoagulation clinics. Thromb Res. 2015; 137:178-183. DOI: 10.1016/j.thromres.2015.12.001. View

10.

Garcia D, Baglin T, Weitz J, Samama M . Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e24S-e43S. PMC: 3278070. DOI: 10.1378/chest.11-2291. View

11.

Sauter T, Eberle B, Wuillemin W, Thiele T, Angelillo-Scherrer A, Exadaktylos A . How I manage patients with anticoagulation-associated bleeding or urgent surgery. Swiss Med Wkly. 2018; 148:w14598. DOI: 10.4414/smw.2018.14598. View

12.

Godier A, Martin A, Leblanc I, Mazoyer E, Horellou M, Ibrahim F . Peri-procedural management of dabigatran and rivaroxaban: Duration of anticoagulant discontinuation and drug concentrations. Thromb Res. 2015; 136(4):763-8. DOI: 10.1016/j.thromres.2015.08.006. View

13.

Flaker G, Theriot P, Binder L, Dobesh P, Cuker A, Doherty J . Management of Periprocedural Anticoagulation: A Survey of Contemporary Practice. J Am Coll Cardiol. 2016; 68(2):217-26. DOI: 10.1016/j.jacc.2016.04.042. View

14.

Samuelson B, Cuker A, Siegal D, Crowther M, Garcia D . Laboratory Assessment of the Anticoagulant Activity of Direct Oral Anticoagulants: A Systematic Review. Chest. 2016; 151(1):127-138. PMC: 5310120. DOI: 10.1016/j.chest.2016.08.1462. View

15.

Heidbuchel H, Verhamme P, Alings M, Antz M, Diener H, Hacke W . Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2015; 17(10):1467-507. DOI: 10.1093/europace/euv309. View

16.

Sauter T, Amylidi A, Ricklin M, Lehmann B, Exadaktylos A . Direct new oral anticoagulants in the emergency department: Experience in everyday clinical practice at a Swiss university hospital. Eur J Intern Med. 2016; 29:e13-5. DOI: 10.1016/j.ejim.2015.12.009. View

17.

Dubois V, Dincq A, Douxfils J, Ickx B, Samama C, Dogne J . Perioperative management of patients on direct oral anticoagulants. Thromb J. 2017; 15:14. PMC: 5433145. DOI: 10.1186/s12959-017-0137-1. View

18.

Kozek-Langenecker S, Afshari A, Albaladejo P, Santullano C, De Robertis E, Filipescu D . Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013; 30(6):270-382. DOI: 10.1097/EJA.0b013e32835f4d5b. View

19.

Douketis J, Wang G, Chan N, Eikelboom J, Syed S, Barty R . Effect of standardized perioperative dabigatran interruption on the residual anticoagulation effect at the time of surgery or procedure. J Thromb Haemost. 2015; 14(1):89-97. DOI: 10.1111/jth.13178. View

20.

Healey J, Eikelboom J, Douketis J, Wallentin L, Oldgren J, Yang S . Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) randomized trial. Circulation. 2012; 126(3):343-8. DOI: 10.1161/CIRCULATIONAHA.111.090464. View