Understanding the Novel Anticoagulant and Platelet Inhibitory Medications and How They Compare to Their Traditional Counterparts

Statement of Problem:  According to the Centers for Disease Control (CDC), approximately 26.5 million Americans carry a diagnosis of heart disease, over 2.6 million have atrial fibrillation, and as many as half of a million people are diagnosed with deep vein thromboses (DVT) or pulmonary embolisms (PE) each year[1].  As the American population ages and rates of obesity increase, each of those statistics are expected to rise over the foreseeable future.  Many of the patients afflicted with these diagnoses take anticoagulant medications as part of their daily regimen. Oral and Maxillofacial Surgeons work in one of the most vascular parts of the body, the head and neck, and as the statistics indicate, surgeons can expect to frequently encounter patients taking one or more medications that can prolong bleeding or inhibit proper clot formation.  As new drugs enter the market, it is important for Oral and Maxillofacial Surgeons to be aware of the pharmacology of these medications and the proper approaches to treating patients taking them.  

Methods:  We undertook a comprehensive review of common outpatient anticoagulant medications, both new and old.  Recommendations and guidelines from organizations such as the American Heart Association and the American Society of Hematology were analyzed and compiled with emphasis placed on perioperative management in both elective and emergent situations.

Results:  The traditional anticoagulants and anti-platelet agents reviewed were low molecular weight heparin, warfarin, fondaparinux, acetylsalicylic acid, and clopidogrel.  New medications reviewed include dabigatran, prasugrel, ticagrelor, apixaban and rivaroxaban[2,3,4,5].   

Conclusion: Oral and Maxillofacial Surgeons can expect to frequently encounter patients taking anticoagulant and anti-platelet medications.  It is extremely important to be aware of the risks of surgical treatment while patients are taking these drugs and equally important to be aware of emergency protocols for medication reversal, if possible.  We seek to propose an algorithmic approach for the Oral and Maxillofacial Surgeon for treatment planning patients on novel anticoagulation or antiplatelet medications.   

 

References:

 1.      Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: A report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines and the European Socity of Cardiology Committee for Practice Guidelines. Circulation. 2006;114(7):e257–354.

2.      Potpara T, Polovina M, Licina M, Stojanovic R, Prostran M, Lip G.  Novel Anticoagulants for stroke prevention in atrial fibrillation: focus on apixaban.   Adv Ther. 2012; 29(6): 491-507. 

 3.      Siegal D, Cuker A.  Reversal of novel oral anticoagulants in patients with major bleeding.  J Thromb Thrombolysis. 2012; Feb 7 [Epub ahead of print]

 4.      Levy J, Faraoni D, Spring J, Douketis J, Samama C.  Managing new oral anticoagulants in the perioperative and intensive care unit setting.  Anesthesiology. 2013 Feb 14 [Epub ahead of print]

 5.      Angiolillo D.  The evolution of antiplatet therapy in the treatment of acute coronary syndromes: from aspirin to the present day. Drugs 2012; 16(30)2087-2116.