Managing the Medically Compromised Patient University of MN School of Dentistry Clinical Grand Rounds March 5, 2015

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1 Managing the Medically Compromised Patient University of MN School of Dentistry Clinical Grand Rounds March 5, 2015 Kevin Nakagaki, DDS HealthPartners Dental

2 n Desktop or handheld version n Off label uses n Mechanism of Action n Half life n Relative and absolute contraindications n Free! Free! Free!

3 Case Presentations n HIPPA n Composite patient cases

4 Case 1 n 18 year old female patient of record n Mother is in the waiting area n Medication: Coumadin 5mg e/o day; Coumadin 7.5mg e/o day n NKDA n What questions come to mind?

5 Coagulation: Big Topic

6 Case 1 Questions? n What is her INR? n Bleeding episodes? n Why is she on Coumadin? n Was she on BCP? n Factor V Leiden?

7 Factor V Leiden n Inherited thrombophilia n Males and females can be affected n Heterozygous vs homozygous n Activated protein C (APC) n Risk factors: age, obesity, smoking, surgery, BCP/hormone replacement, pregnancy

8 Factor V Leiden Management n INR? n Routine dental care (non-surgical): no modification of medication n Extensive surgical procedures: work with the patient s hematologist n May consider bridging n Be prepared to manage bleeding

9 Bridging n Coumadin (warfarin) n Heparin n Low molecular weight heparin n Pradaxa (dabigatran) mg bid n Eliquis (apixaban) 2.5-5mg bid n Xarelto (rivaroxaban) 10-20mg qd

10 Bridging: Half life n Coumadin (warfarin) 20-60h n Heparin 1.5h n Low molecular weight heparin 4.5-7h n Pradaxa (dabigatran) 12-17h n Eliquis (apixaban) 12h n Xarelto (rivaroxaban) 5-13h

11 Bridging: Half life n Expose the patient to the least amount of risk n Add the 2nd anticoagulant (with a shorter half life) n Wean the patient off the primary anticoagulant (or reverse the anticoagulant) n Stop the 2nd anticoagulant n Complete the surgery; establish hemostasis n Start the 2nd anticoagulant; add the primary anticoagulant n Stop the 2nd anticoagulant

12 Case #2 n 68yo male admitted to the hospital n Mechanical mitral valve replacement n Seizure disorder n Congestive heart failure n On coumadin therapy n Uncontrolled oral bleeding

13 Case #2 n INR 9.0 (multiple factors); platelets 70,000 n Patient aspirated blood, lost consciousness n Intubated and transported to the hospital n Coumadin was reversed; INR 1.6 n Bridged with IV heparin n 3 teeth identified (all exhibited +3 mobility)

14 Case #2 WWYD? n d/c heparin n Antibiotic prophylaxis (considerations?) n Extract the teeth (platelet considerations?) n Establish hemostasis n Re-start heparin n Re-establish therapeutic INR w/ coumadin n d/c heparin

15 Case #3 n 55yo female SCCA right base of tongue n Previously treated by excision, no radiation/ chemotherapy n Presents with a bad taste in her mouth

16 Case #4 n 63yo male n SCCa right tonsil n Completed radiation/chemotherapy n Now complains of a sore tongue

17 Case #4 n HBO: sessions n Extract the tooth and debride the area n HBO: 10 sessions n Antibiotics n Chorhexidine

18 Case #4 6 months later n I have a sore on my tongue n 2mm of bony sequestrum protruding from the right mandible adjacent to the former #30; very mobile n WWYD?

19 Head and Neck Cancer n Complications arise n Preventive care as much as possible n Pre-XRT/chemo extractions? n Frequent recalls until stable n Management of ORN n HBO provides a life-long benefit

20 Thanks

21 Coumadin (Warfarin) n Affects the Vit. K dependent portion of the extrinsic pathwayà no fibrin clot formation n 2-4 days to reach therapeutic levels n 1-3 days to decrease INR to an acceptable level n Beware drug interactions several will increase bleeding risk (Cyt P450). (epocrates.com!!) n Can be reversed with Vit. K

22 Coumadin Drug Interactions: increase the chance of bleeding n Allopurinol n Anabolic steroids n Aspirin n Amiodarone n Capecitabine n Cephalosporins n Ciprofloxacin n Clofibrate n Clopidogrel n Diclofenac n Disulfiram n Erythromycin n Cimetidine

23 Coumadin Drug Interactions: increased risk of thrombosis n Azathoprine n Antithyroid medication n Carbamazepine n Dicloxacillin n Glutethimide n Griseofulvin n Haloperidol n Nafcilllin n Oral contraceptives n Phenobarbital n Rifampin n Vitamin K

24 Coumadin Food Interactions: Vitamin K n n n n n n n n Beef liver Broccoli Brussel sprouts Cabbage Chard Cheese Collard greens Green tea n Kale n Lentils n Lettuce n Mustard Greens n Spinach n Soybean oil n Turnip greens

25 Coumadin Food Interactions: Increased Bleeding n Cranberry Juice n Alcohol

26 INR-- What s Acceptable? n Several Factors: Ask the next question! 1. Risk for another event (Stroke, DVT, Pulmonary Embolism, etc.) Who is at the highest risk? 2. Time since the last event 3. Patient s Hx of bleeding/bruising look for petechia 4. Baseline INR 5. Your procedure (Exts. vs Sc/rp)

27 Coumadin General Guidelines n Be prepared to manage the bleeding n INR 3.5 and low risk for another event, and low risk procedure: No change in coumadin n INR > 3.5 and low risk procedure: Consult with M.D., consider discontinuing dose until INR < 3.0

28 Coumadin (cont.) n INR > 3.5, high risk for another event, high risk procedure: Consult with M.D., consider bridging with heparin (LMW or IV) n Consider Gowe-Gates injection; infiltration/ infrabony injection n Restart the coumadin in the evening of the surgery n High risk procedures: any surgery involving multiple exts. or flap

29 New Anticoagulants for Atrial Fibrillation (AF) n Est. 2.6 million American have AF n AF is responsible for 15-20% of all strokes n Untreated AF stroke risk is approx. 5% n Anticoagulation Tx does lower incidence and severity of AF stroke n < 60% of AF pts have received anticoagulation with coumadin--many are below targeted INR Am J Med. 2010; 123: N Engl J Med. 2003; 349:

30 Looking for the Ideal Anticoagulant n High efficacy-to-safety index n Predictable dose response (no monitoring) n Parenteral and oral administration n Rapid onset of action n Antidote n Minimal side effects n Minimal drug-drug interactions Blood. 2005; 105(2);

31 New Oral Anticoagulants n Direct thrombin (IIa) inhibitor Dabigatran (Pradaxa) n Factor Xa inhibitors Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Lixiana/Savaysa) Afib and VTE

32 Dabigatran (Pradaxa)--basics n Direct thrombin (factor IIa) inhibitor n Max anticoag activity 2-3 hours after ingestion n Half life hours (11.5 hours average) n Metabolism--conjugation n Elimination--renal (80%), remainder excreted in bile n Contraindicated in patients with CrCl <30ml/min n Main side effect--dyspepsia (10%)

33 Dabigatran (Pradaxa) Implications of Dabigatran, a Direct Thrombin Inhibitor, for Oral Surgery Practice J Can Dent Assoc 2013;79:d74

34 Dabigatran (Pradaxa)--basics n Drug-drug interactions--least likely to have drug interactions n No P450 interactions n P glycoprotein substrate n Amiodarone (increases level by 60%), verapamil,rifampin, clarithromycin, quinidine (contraindicated) n Proton pump inhibitors: Reduce absorption by 20-30% n No drug-food interactions n Food delays absorption, not clinically significant n Antidote: No Antidote n Dialyzable

35 Rivaroxaban (Xarelto) the basics n Drug interactions--most likely to have interaction n CYP 3A4 and P glycoprotein substrate n Drugs that are substrates for both may cause more significant interaction n Ketoconazole, ritonavir, clarithromycin, erythromycin (increase levels %) n Rifampin (decrease levels 50%) n Drug-food interactions (low) n Recommended to be taken with food n H2blockers, antacids no effect; no info on PPIs

36 Rivaroxaban (Xarelto) the basics n Direct factor Xa inhibitor n Peak plasma concentration hours after administration n Half life hours n Metabolism: oxidation (via CYP3A4 and CYP2J2) and hydrolysis n Elimination--2/3 renal, 1/3 fecal n Antidote: Factor Xa n Not affected by dialysis

37 Apixaban (Eliquis) the basics n n n n n n n n n Direct factor Xa inhibitor Time to peak AC effect hours Half life hours Metabolism--oxidation (via CYP3A4) and conjugation Elimination--25% renal, 75% fecal Drug drug interactions Likely CYP3A4 interactions, but no data available Drug-food interactions (low) Antidote: Factor Xa

38 New Oral Anticoagulants

39 Extractions? n Consider the risks n For bleeding n For excessive clotting n What tools do we have to control hemorrhage?

40 Extractions n The new anticoagulants are approved to treat atrial fibrillation n Therapeutic ranges are similar to coumadin for atrial fibrillation (INR ) n For the new anticoagulants, the doseresponse is linear

41 Managing Bleeding n Gelfoam n Topical Thrombin n Surgicel n Avatine ($$$) n Collacoat ($) n Bone wax n Platelets n DDAVP (vwd) n Amicar Rinse n Factor

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