New Oral Anticoagulants

OMFS Guidelines New Oral AnticoagulantsSue SandersElective Care Divisional Quality BoardMay 2013 The New Oral Anticoagulants.Generic Dabigatran Rivaroxaban Apixaban

Trade Pradaxa Xarelto Eliquis

Mode of ActionDabigatran (Pradaxa) is a thrombin inhibitor

Rivaroxaban (Xarelto) and Apixaban (Eliquis) are inhibitors of activated Factor Xa

Warfarin is a Vitamin K antagonist. Factors II, VII, IX, XNOACs Background2008

Registered for the Primary prevention of VTE in adults undergoing total hip and knee replacements.NOACs Background

2011Approved for the prevention of stroke and systemic embolism in adults with non valvular atrial fibrillation with one or more risk factors:-previous stroke, TIA or systemic embolismleft ventricular ejection fraction 75Age surgery 8pm)Least possible traumaWound should be suturedPatient can only leave when bleeding completely stopped.Tranexamic Acid M/W 5% QDS 5/7 (clot stabilisation only)Oral and written instructionsPatient to contact dentist in case of bleeding that does not stop spontaneously.Dentist to be available after hours

NOACs Heidbuchel et al 2011RecommendationsIf the decision is to discontinue Dabigatran should be stopped 24h prior to extraction and resumed once haemostasis is achieved.

For more extensive intervention the patient should be referred to a maxillofacial surgeon!

NOACs So whats the Problem Part V?There has been an exponential rise in prescribing

15 patients Dec 2012Over 150 patients May 2013400 patients are eligibleRivaroxaban will be the drug of choice.No new patients will be Rx Dabigatran

Michelle Grundy Anticoagulation Service Waters Meeting HC NOACs The Future?

Warfarin 3p each Rivaroxaban 1.71 each Apixaban 2.10 each Dabigatran 1.26 each

Monitoring No Monitoring

NOACs the solution? Awareness and vigilance. Guidelines for management of NOAC patients - minor procedures - major procedures elective (+/- bridging) - emergency haemorrhage protocol Audit

NOACs Draft GuidelinesSafe.Universal.Suitable for both Primary, Tier 2 and Secondary care.Clear for the clinician.Clear and easy for the patient to follow. NOACs Draft Guidelines (Proposed )Omit NOAC on the morning of surgery.Usual local measures / judicious extractions etc.Recommence NOAC the following day.

For simple elective procedures such as extractions, apicetomies, biopsies, soft tissue surgery, and some fractures excluding orbital floor injuries.

NOAC Guidelines For emergency surgery, or more major procedures including Head and Neck, orbital floor surgery, Parotid / submandibular gland surgery, soft tissue surgery in the neck etc haematology advice should be sort on a case by case basis, particularly in respect of recommencing NOACs in situations where post op bleeding could be problematic. NOACs Draft GuidelinesLow Clot Risk patients. PE/DVT >6 anticoagulated >6 weeks Atrial fibrillation Peripheral vascular disease.High clot risk patients.PE/DVT within last 6 weeks (surgery should be deferred if possible)Recurrent PE/DVTProsthetic heart valvesAntiphospholipid syndromePatients with active cancerAF patients with a previous stroke or TIA

NOAC Draft GuidelinesComplies with the Trust Draft Guidelines for Anticoagulation of Adult Patients (consultation)Dabigatran, rivaroxaban, apixaban and other newer oral anticoagulants (NOACs) have quick onset of action so do not require a switch over to heparin for high clot risk patients as required with Warfarin. This also means that high and low clot risk patients are dealt with in the same way i.e. for elective procedures simply stop the drug and allow 24 hours to elapse before surgery commences. In patients with renal failure longer may be required (Dabigatran). NOACs can be recommenced 24 hours post op. NOAC Draft GuidelinesOMFS proposed guidelines have been approved by:

Dr Mark Grey Consultant Haematologist

Dr Ambar Basu Chair, Hospital Thrombosis Committee NOAC Audit ProposalProspective audit of all NOAC patients presenting for surgery extractions, biopsies, I & D, trauma, H & N, across the Unit.

Audit any post extraction haemorrhage patients presenting via A & E and the treatment room at Blackburn.

Thank you