Volume 182 - Issue 7
Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis
Author: Max Kamien
Med J Aust 2005; 182 (7): 365-368. || doi: 10.5694/j.1326-5377.2005.tb06744.x
Published online: 4 April 2005
Published online: 4 April 2005
To the Editor: A middle-aged woman with atrial fibrillation had her warfarin therapy stopped for 2 days before dental extraction. She had a catastrophic stroke and is now a plaintiff. I was asked if her medical management accorded with common practice.
At the October 2004 Annual Conference of the Royal Australian College of General Practitioners, I conducted a straw poll of 20 experienced GPs, of whom 18 said they would stop warfarin for between 2 and 4 days before a dental extraction. Some of these GPs regarded a dental extraction as elective surgery and pointed me to authoritative (but slightly ambiguous) sources to back up their view. 1,2 However, a review of the medical and dental literature shows that this is an example of common practice lagging behind clinical evidence.
The first controlled trial of dental extraction in patients on warfarin therapy was conducted in 1983.3 It showed that it was not necessary to cease warfarin prophylaxis for patients whose international normalised ratio (INR) was within the normal therapeutic range. Since then, two major literature reviews have confirmed these conclusions.4,5 A recent Australian review on warfarin reversal expresses a similar point of view.6 The incidence of a serious embolic complication from stopping therapy with warfarin is 1%, and this is three times more likely to occur than bleeding complications in patients whose warfarin therapy was continued.4 Furthermore, a stroke is a catastrophic event, while a bleeding tooth socket is simply messy and usually easily controlled.
An authoritative review and position statement on warfarin therapy and dental procedures from the Australasian Society of Thrombosis and Haemostasis may be the catalyst required to align common practice with clinical evidence.
References
- Australian Medicines Handbook. Adelaide: Hyde Park Press, 2004: 310. BABEHIHA
- Hankey GJ. Non-valvular atrial fibrillation and stroke prevention. National Blood Pressure Advisory Committee of the National Heart Foundation. Med J Aust 2001; 174: 234-239. <eMJA full text>
- Bailey BM, Fordyce AM. Complications of dental extraction in patients receiving warfarin anti-coagulant therapy. A controlled trial. Br Dent J 1983; 155: 308-310. i1085681
- Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy [review]. J Am Dent Assoc 2000; 131: 77-81. i1085683
- Carter G, Goss AN, Lloyd J, Tocchetti R. Current concepts in the management of dental extractions for patients taking warfarin. Aust Dent J 2003; 48: 89-96. i1085685
- Baker RI, Coughlin PB, Gallus AS, et al. Warfarin reversal: consensus guidelines on behalf of the Australasian Society of Thrombosis and Haemostasis. Med J Aust 2004; 181: 492-497. <eMJA full text>