Anticoagulation/Antiplatelet Medications and Considerations

Uses

• Antiplatelet medications and anticoagulants work to prevent clots in blood vessels.
• Antiplatelets medication interfere with platelet aggregations, which is the start for blood clot formation.
• Anticoagulants interfere with different factors the coagulation process. The coagulation process attempts to stabilize a blood clot.

Anticoagulation therapy guidelines

Routine dental care, including simple extractions, can be performed with a PT <20 seconds or an INR <3.5.

• PT and INR should be measured within 24 hours to be considered valid.
• Anticoagulation level is measured by prothrombin time (PT) and international normalized ratio (INR).
• PT – Normal range is 11-13 seconds; goal for anticoagulation is 16-20 seconds.
• INR – normal range is 1.0-1.3; goal for anticoagulation is 2.5-4.5.
• Only a physician should make changes to a patient’s anticoagulation therapy.
• If coumadin (Warfarin), a vitamin K antagonist, is discontinued, the effect will take place only 2 days later. If no alternative anticoagulation therapy is instituted during this time, there is an increased risk for the patient to develop a thromboembolic event.
• Alternative anticoagulation therapy includes fractionated and unfractionated (low molecular weight heparin [LMWH]) heparin.
• Apixaban (Eliquis), a novel direct factor Xa inhibitor, has been shown to be beneficial in patients with atrial fibrillation to prevent the incidence of strokes.
• Other new alternatives to warfarin therapy are rivaroxaban (Xarelto), another factor Xa inhibitor, and dabigatran (Pradaxa), a direct thrombin inhibitor.
• DO NOT discontinue warfarin therapy within the first 6 months after bioprosthetic aortic valve replacement.

Antiplatelet therapy guidelines

• No need to discontinue aspirin, or aspirin in combination with other antiplatelet medications, used to prevent thromboembolic events, for routine dental procedures or simple extractions.
• DO NOT discontinue dual antiplatelet therapy in patients within the first year after the placement of coronary artery stents.

Anticoagulation and antiplatelet medications

Drug Category	Generic name	Trade name
Antiplatelet agents	Aspirin Aspirin and dipyridamole Cilostazol Dipyridamole	Aspirin Aggrenox Pletal Persantine
Intravenous antiplatelet (glycoprotein IIb/IIIa inhibitors)	Abciximab Eptifibatide Tirofiban	ReoPro Integrilin Aggrastat
Oral antiplatelet (P2Y12 Inhibitor)	Cangrelor Clopidogrel Prasugrel Ticagrelor Ticlopidine	Kangreal Plavix Effient Brilinta Ticlid
Anticoagulant (coumarins ans indandiones)	Warfarin	Coumadin, Jantoven
Anticoagulant (factor Xa inhibitors)	Apixaban Betrixaban Endoxaban Fondaparinux Rivaroxaban‡	Eilquis Bevyxxa Savaysa Arixtra Xarelto
Anticoagulant (heparins)	Dalteparin Danaparoid Endoxaparin Tinzaparin	Fragmin Orgaran Lovenox Innohep
Anticoagulant (thrombin inhibitors)	Bivalirudin Dabigatran Desirudin Lepirudin	Angiomax Pradaxa Lixiana Refludan

Considerations for invasive dental procedures

(Tables adapted from Sousa-Uva M, et al.)

P2Y12 Inhibitors	Clopidogrel	Prasugel	Ticagrelor	Cangrelor
Bioavailability	50%	80%	36%	100%
Half-life	1-2 hours	2-15 hours	7-9 hourd	3-6 minutes
Frequency of administration	Once daily	Once daily	Twice daily	IV infusion
Duration of effect	3-10 days	7-10 days	3-5 days	1-2 hours
Antidote	No	No	No	No
Discontinuation before non-acute surgery	At least 5 days	At least 7 days	At least 3 days	1 hour

Vitamin K Antagonists	Acenocoumarol (not approved by U.S. FDA)	Coumadin (Warfarin)	Fluindione	Phenprocoumon
Half-life	10 hours	35-80 hours	30-40 hours	3-4 days
Steady state	2-3 days	3-4 days	3-4 days	6 days
Duration of effect	2-4 days	4-5 days	2-3 days	4-5 days

Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)	Apixaban	Dabigatran	Edoxaban	Rivaroxaban
Target	Factor Xa	Thrombin	Factor Xa	Factor Xa
Tmax	3 hours	2 hours	1-3 hours	2-4 hours
Half-life	9-14 hours	14-17 hours	5-11 hours	9-13 hours
Renal excretion	25%	80%	36-45%	66% (half inactive)
Antidote	Andexanet alfa (Andexxa)	Idarucizumab	Andexanet alfa (Andexxa)	Andexanet alfa (Andexxa)
Discontinuation before non-acute surgery	At least 48 hours	At least 48 -96 hours	At least 48 hours	At least 48 hours

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Medical Complexity Status - Anticoagulation/Antiplatelet Therapy

Anticoagulation/ antiplatelet therapy	MCS1B
Anticipated complication	Controlled/ stable
Hemostasis	Minor
Microbial  susceptibility	None
Drugs/ drug  interactions	None
Stress/trauma	None

See Medical Complexity Status for more information.

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Related Pages

• Medical Disorders
  • Atrial Fibrillation
  • Bleeding Disorders
  • Cardiovascular Disease
  • Stroke
• Oral Health Care Considerations
  • Bleeding Disorders
• Laboratory Values
  • Bleeding Tendencies
  • Laboratory Values for Different Bleeding Disorders

References/Websites

• References
  • Aframian DJ, et al. Management of dental patients taking common hemostasis-altering medications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(suppl 1):S45.e1-S45.e11.
  • Baron TH, et al. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 2013;368(22):2113-24.
  • Engelen ET, at al. Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD012293
  • Grines CL, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents. J Am Dent Assoc. 2007;138(5):652-5.
  • Halpern LR, et al. Treatment of the Dental Patient with Bleeding Dyscrasias: Etiologies and Management Options for Surgical Success in Practice. Dent Clin North Am. 2020;64(2):411-434.
  • Kaplovitch E, et al. Treatment in the dental practice of the patient receiving anticoagulation therapy. J Am Dent Assoc. 2019;150(7):602-608.
  • Kumbhani DJ, et al. 2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease. JACC. 2021;77(5):629-658.
  • Mahmood H, et al. Antiplatelet drugs: a review of pharmacology and the perioperative management of patients in oral and maxillofacial surgery. Ann R Coll Surg Engl. 2020 Jan;102(1):9-13.
  • Romney G, Glick M. An Updated concept of coagulation with clinical implications. J Am Dent Assoc. 2009;140(5):567-74.
  • Sousa-Uva M, et al. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. European Journal of Cardio-Thoracic Surgery. 2018; 53(1):5–33.
  • Weltman NJ, et al. Management of dental extractions in patients taking warfarin as anticoagulant treatment: a systematic review. J Can Dent Assoc. 2015;81:f20.