New Oral Anticoagulants (NOACs): FAQs

This summary is based on the article published in the Canadian Family Physician: Approach to the new oral anticoagulants in family practice Part 2: addressing frequently asked questions (November 2014)

James Douketis MD FRCPC, Alan David Bell MD CCFP, John Eikelboom MBBS FRCPC, Aaron Liew MBBCh MRCPI PhD

You can access the full-text article here.

Intent of the article

To address common “what if” questions that arise relating to the long-term clinical follow-up and management of patients receiving the new oral anticoagulants (NOACs).

Main Message

What if a patient who is taking an NOACs needs dental work? 

• For patients who need teeth cleaning, tooth extraction, or root canal procedures, NOACs can be continued around the time of the procedure as long as patients receive oral prohemostatic mouthwash (eg, tranexamic acid) before and after the procedure. ^{1, 2}
• If substantial bleeding is expected, the patient should skip 1 to 2 days of the NOAC before the procedure and resume the NOAC on the evening after the procedure. ¹ Periprocedural continuation of NOACs (as with warfarin) is usually safe for patients who require other minor procedures such as skin cancer removal, joint injection, or cataract removal. ¹

• Does it matter if NOACs are taken with meals? Dabigatran and rivaroxaban should be taken with meals to decrease dyspepsia and increase absorption, respectively.
• Are there any foods or beverages that should be avoided by NOAC users? There are no dietary restrictions with any of the NOACs, beyond moderating alcohol intake, and rivaroxaban and apixaban can be crushed if required.
• The use of acid suppressive therapies does not appear to affect the efficacy of the NOACs.
• Can NOAC users take acetylsalicylic acid or other antiplatelet drugs? Can NOAC users take nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen? As with warfarin, patients taking NOACs should avoid long-term use of nonsteroidal anti-inflammatory and antiplatelet drugs.
• What if a patient who is taking an NOAC needs surgery? For patients requiring surgery, generally NOACs should be stopped 2 to 5 days before the procedure, depending on bleeding risk, and the NOAC should usually be resumed at least 24 hours after surgery.
• Does a patient taking an NOAC need routine coagulation blood testing before surgery? Preoperative coagulation testing is generally unnecessary.
• What if a patient develops minor bleeding? In patients who develop bleeding, minor bleeding typically does not require laboratory testing or discontinuation of NOACs.
• What if a patient develops major bleeding? With major bleeding, the focus should be on local measures to control the bleeding and supportive care, and coagulation testing should be performed.
• There are currently no antidotes to reverse NOACs.
• Can NOACs be used in patients with AF and valvular heart disease? Can NOACs be used in patients with mechanical prosthetic heart valves? Can NOACs be used in patients with bioprosthetic heart valves? Can NOACs be used in patients with cancer-associated deep vein thrombosis (DVT)? Can NOACs be used for patients with superficial thrombophlebitis? NOACs should not be used in patients with valvular heart disease, prosthetic heart valves, cancer-associated deep vein thrombosis, or superficial thrombophlebitis.

Additional Resource

• Mayo Clinic The New Oral Anticoagulants in Clinical Practice

References

1. Douketis JD. Pharmacologic properties of the new oral anticoagulants: a clinician-oriented review with a focus on perioperative management. Curr Pharm Des 2010;16(31):3436-41.
2. Alikhan R, Rayment R, Keeling D, Baglin T, Benson G, Green L, et al. The acute management of haemorrhage, surgery and overdose in patients receiving dabigatran. Emerg Med J 2013;31(2):163-8.