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

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Betty Rogers
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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

Activated protein C (APC) n Risk factors: age,

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

(or reverse the anticoagulant) n Stop the 2nd anticoagulant n Complete the surgery;

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

Anticoagulants. Denver Health April 12, 2011

Anticoagulants. Denver Health April 12, 2011 New Oral Anticoagulants Rebecca Hanratty, MD Denver Health April 12, 2011 Overview Why we need alternatives to warfarin Review of the 3 new oral anticoagulants Results from major trials: Thromboprophylaxis