Advances in Antiplatelet Therapy for Dentofacial Surgery Patients: Focus on Past and Present Strategies

Background: Nowadays, patients involved in antiplatelet therapy required special attention during oral surgery procedures, due to the antiplatelet drugs assumption. The motivations of the assumption may be different and related to the patient’s different systemic condition. For this reason, accordingly to the current international guidelines, different protocols can be followed. The aim of this work is to analyze how the dentist’s approach to these patients has changed from the past to the present, evaluating the risk exposure for the patients. Methods: This review paper considered different published papers in literature through quoted scientific channels, going in search of “ancient” works in such a way as to highlight the differences in the protocols undertaken. The analyzed manuscripts are in the English language, taking into consideration reviews, case reports, and case series in such a way as to extrapolate a sufficient amount of data and for evaluating the past therapeutic approaches compared to those of today. Results: Colleagues in the past preferred to subject patients to substitution therapy with low molecular weight anticoagulants, by suspending antiplatelet agents to treatment patients, often for an arbitrary number of days. The new guidelines clarify everything, without highlighting an increased risk of bleeding during simple oral surgery in patients undergoing antiplatelet therapy. Conclusion: Either patients take these medications for different reasons, because of cardiovascular pathologies, recent cardiovascular events, or even for simple prevention, although the latest research shows that there is no decrease of cardiovascular accidents in patients who carry out preventive therapy. Surely, it will be at the expense of the doctor to assess the patient’s situation and risk according to the guidelines. For simple oral surgery, it is not necessary to stop therapy with antiplatelet agents because the risk of bleeding has not increased, and is localized to a post-extraction alveolus or to an implant preparation, compared to patients who do not carry out this therapy. From an analysis of the results it emerges that the substitutive therapy should no longer be performed and that it is possible to perform oral surgery safely in patients who take antiplatelet drugs, after a thorough medical history. Furthermore, by suspending therapy, we expose our patients to more serious risks, concerning their main pathology, where present.

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Antiplatelet drugs: a review of pharmacology and the perioperative management of patients in oral and maxillofacial surgery

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0154 ◽

2020 ◽

Vol 102 (1) ◽

pp. 9-13

Author(s):

H Mahmood ◽

I Siddique ◽

A McKechnie

Keyword(s):

Antiplatelet Therapy ◽

Oral Surgery ◽

Safety Concern ◽

Maxillofacial Surgery ◽

Antiplatelet Agents ◽

Antiplatelet Drugs ◽

Current Evidence ◽

Bleeding Complications ◽

Oral And Maxillofacial Surgery ◽

Number Of Patients

Introduction An increasing number of patients are taking oral antiplatelet agents. As a result, there is an important patient safety concern in relation to the potential risk of bleeding complications following major oral and maxillofacial surgery. Surgeons are increasingly likely to be faced with a dilemma of either continuing antiplatelet therapy and risking serious haemorrhage or withholding therapy and risking fatal thromboembolic complications. While there are national recommendations for patients taking oral antiplatelet drugs undergoing invasive minor oral surgery, there are still no evidence-based guidelines for the management of these patients undergoing major oral and maxillofacial surgery. Methods MEDLINE and EMBASE databases were searched to retrieve all relevant articles published to 31 December 2017. Findings A brief outline of the commonly used antiplatelet agents including their pharmacology and therapeutic indications is discussed, together with the haemorrhagic and thromboembolic risks of continuing or altering the antiplatelet regimen in the perioperative period. Finally, a protocol for the management of oral and maxillofacial patients on antiplatelet agents is presented. Conclusions Most current evidence to guide decision making is based upon non-randomised observational studies, which attempts to provide the safest possible management of patients on antiplatelet therapy. Large randomised clinical trials are lacking.

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Comparative Efficacy and Safety of Duration of Dual Antiplatelet Therapy in Patients with CAD Undergoing Drug-eluting Stent Implantation: A Systematic Review and Network Meta-analysis

Current Pharmaceutical Design ◽

10.2174/1381612826666200625110349 ◽

2020 ◽

Vol 26 (44) ◽

pp. 5739-5745

Author(s):

Jieqiong Guan ◽

Wenjing Song ◽

Pan He ◽

Siyu Fan ◽

Hong Zhi ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Major Bleeding ◽

Dual Antiplatelet Therapy ◽

Meta Analysis ◽

Cochrane Library ◽

Drug Eluting Stent ◽

Efficacy And Safety ◽

Risk Of Bleeding ◽

Increased Risk ◽

Drug Eluting

Objective: The aim was to evaluate the efficacy and safety of duration of dual antiplatelet therapy (DAPT) for patients who received percutaneous coronary intervention (PCI) with a drug-eluting stent. Background: The optimal duration of DAPT to balance the risk of ischemia and bleeding in CAD patients undergoing drug-eluting stent (DES) implantation remains controversial. Methods: PubMed, Cochrane Library, Web of Science, Clinicaltrials.gov, CNKI and Wanfang Databases were searched for randomized controlled trials of comparing different durations of DAPT after DES implantation. Primary outcomes were major adverse cardiac and cerebrovascular events (MACCE), and major bleeding, and were pooled by Bayes network meta-analysis. Net adverse clinical and cerebral events were used to estimate the surface under the cumulative ranking (SUCRA) curves. The subgroup analysis based on clinical status, follow-up and area was conducted using traditional pairwise meta-analysis. Results: A total of nineteen trials (n=51,035) were included, involving six duration strategies. The network metaanalysis showed that T2 (<6-month DAPT followed by aspirin, HR:1.51, 95%CI:1.02-2.22), T3 (standard 6-month DAPT, HR:1.47, 95%CI:1.14-1.91), T4 (standard 12-month DAPT, HR:1.41, 95%CI:1.15-1.75) and T5 (18-24 months DAPT, HR:1.47, 95%CI:1.09-1.97) was associated with significantly increased risk of MACCE compared to T6 (>24-month DAPT). However, no significant difference was found in MACCE risk between T1 (<6-month DAPT followed by P2Y12 monotherapy) and T6. Moreover, T5 was associated with significantly increased risk of bleeding compared to T1(RR:3.94, 95%CI:1.66-10.60), T2(RR:3.65, 95%CI:1.32-9.97), T3(RR:1.93, 95%CI:1.21-3.50) and T4(RR:1.89, 95%CI:1.15-3.30). The cumulative probabilities showed that T6(85.0%), T1(78.3%) and T4(44.5%) were the most efficacious treatment compared to the other durations. In the ACS (<50%) subgroup, T1 was observed to significantly reduce the risk of major bleeding compared to T4, but not in the ACS (≥50%) subgroup. Conclusions: Compared with other durations, short DAPT followed by P2Y12 inhibitor monotherapy showed non-inferiority, with a lower risk of bleeding and not associated with an increased MACCE. In addition, the risk of major bleeding increased significantly, starting with DAPT for 18-month. Compared with the short-term treatment, patients with ACS with the standard 12-month treatment have a better prognosis, including lower bleeding rate and the decreased risk of MACCE. Due to study's limitations, the results should be verified in different risk populations.

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Systematic review to investigate the safety of induction and augmentation of labour among pregnant women with iron-deficiency anaemia

BMJ Open ◽

10.1136/bmjopen-2018-021793 ◽

2018 ◽

Vol 8 (12) ◽

pp. e021793 ◽

Cited By ~ 1

Author(s):

Kathryn Bunch ◽

Nia Roberts ◽

Marian Knight ◽

Manisha Nair

Keyword(s):

Systematic Review ◽

Iron Deficiency ◽

Pregnant Women ◽

Iron Deficiency Anaemia ◽

Case Reports ◽

Case Series ◽

Severe Anaemia ◽

Risk Of Bias ◽

Deficiency Anaemia ◽

Increased Risk

ObjectiveTo conduct a systematic review to investigate the safety of induction and/or augmentation of labour compared with spontaneous-onset normal labour among pregnant women with iron-deficiency anaemia.DesignSystematic review.SettingStudies from all countries, worldwide.PopulationPregnant women with iron-deficiency anaemia at labour and delivery.InterventionAny intervention related to induction and/or augmentation of labour.Outcome measuresPrimary: Postpartum haemorrhage (PPH), heart failure and maternal death. Secondary: Emergency caesarean section, hysterectomy, admission to intensive care unit.MethodWe searched 10 databases, including Medline and Embase, from database inception to 1 October 2018. We included all study designs except cross-sectional studies without a comparator group, case reports, case series, ecological studies, and expert opinion. The searches were conducted by a healthcare librarian and two authors independently screened and reviewed the studies. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approachto ascertain risk of bias and conducted a narrative synthesis.ResultsWe identified 3217 journal articles, 223 conference papers, 45 dissertations and 218 registered trials. Ten articles were included for full-text review and only one was found to fulfil the eligibility criteria. This was a retrospective cohort study from India, which showed that pregnant women with moderate and severe anaemia could have an increased risk of PPH if they underwent induction and/or augmentation of labour, but the evidence was weak (graded as ‘high risk of bias’).ConclusionThe best approach is to prevent anaemia, but a large number of women in low-to-middle-income countries present with severe anaemia during labour. In such women, appropriate peripartum management could prevent complications and death. Our review showed that at present we do not know if induction and augmentation of labour is safe in pregnant women with iron-deficiency anaemia and further research is required.PROSPERO registration numberCRD42015032421.

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Risk of colonoscopic post-polypectomy bleeding in patients on single antiplatelet therapy: systematic review with meta-analysis

Surgical Endoscopy ◽

10.1007/s00464-021-08975-0 ◽

2022 ◽

Author(s):

Marco Valvano ◽

Stefano Fabiani ◽

Marco Magistroni ◽

Antonio Mancusi ◽

Salvatore Longo ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Meta Analysis ◽

Antiplatelet Agents ◽

Disease Recurrence ◽

Major Adverse Cardiovascular Events ◽

Control Group ◽

P2y12 Inhibitors ◽

Randomized Controlled ◽

Electronic Search ◽

Increased Risk

Abstract Background It was not yet fully established whether the use of antiplatelet agents (APAs) is associated with an increased risk of colorectal post-polypectomy bleeding (PPB). Temporarily, discontinuation of APAs could reduce the risk of PPB, but at the same time, it could increase the risk of cardiovascular disease recurrence. This study aimed to assess the PPB risk in patients using APAs compared to patients without APAs or anticoagulant therapy who had undergone colonoscopy with polypectomy. Methods A systematic electronic search of the literature was performed using PubMed/MEDLINE, Scopus, and CENTRAL, to assess the risk of bleeding in patients who do not interrupt single antiplatelet therapy (P2Y12 inhibitors or aspirin) and undergone colonoscopy with polypectomy. Results Of 2417 identified articles, 8 articles (all of them were non-randomized studies of interventions (NRSI); no randomized controlled trials (RCT) were available on this topic) were selected for the meta-analysis, including 1620 patients on antiplatelet therapy and 13,321 controls. Uninterrupted APAs single therapy was associated with an increased risk of PPB compared to the control group (OR 2.31; CI 1.37–3.91). Patients on P2Y12i single therapy had a higher risk of both immediate (OR 4.43; CI 1.40–14.00) and delayed PPB (OR 10.80; CI 4.63–25.16) compared to the control group, while patients on aspirin single therapy may have a little to no difference increase in the number of both immediate and delayed PPB events. Conclusions Uninterrupted single antiplatelet therapy may increase the risk of PPB, but the evidence is very uncertain. The risk may be higher in delayed PPB. However, in deciding to discontinue APAs before colonoscopy with polypectomy, the potential higher risk of major adverse cardiovascular events should always be assessed.

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Drugs Implicated, Mortality and Use of Corticosteroids in Toxic Epidermal Necrolysis Cases: A Systematic Review of Published Case Reports and Case Series

Journal of Postgraduate Medicine Education and Research ◽

10.5005/jp-journals-10028-1118 ◽

2014 ◽

Vol 48 (3) ◽

pp. 132-138

Author(s):

Sunil Dogra ◽

Samir Malhotra ◽

Promila Pandhi ◽

Sharonjeet Kaur ◽

Sujit Rajagopalan ◽

...

Keyword(s):

Systematic Review ◽

Toxic Epidermal Necrolysis ◽

Case Reports ◽

Case Series ◽

Developed Countries ◽

Mortality Rates ◽

The Past ◽

Changing Trends ◽

Nonsignificant Difference ◽

Developing And Developed Countries

ABSTRACT Background Toxic epidermal necrolysis (TEN) is a rare idiosyncratic mucocutaneous reaction associated with high mortality. Drugs are most commonly implicated in TEN. The treatment constitutes stopping the offending drug, along with symptomatic management. In this study, we searched for case reports/series of TEN and analyzed data to find the most commonly implicated drugs in TEN, effects of use of corticosteroids on mortality in TEN patients, changing trends in mortality over the past 3 decades and difference in mortality rates in both developing and developed countries. Materials and methods We searched for case reports/series of TEN to evaluate most commonly implicated drugs in TEN, effects of use of corticosteroids on mortality in TEN patients, changing trends in mortality over the past three decades and difference in mortality rates in both developing and developed countries. Results Antibiotics (28.6%) followed by antiepileptics (17.4%) and nonsteroidal anti-inflammatory drugs (9.6%) are most commonly implicated. There was nonsignificant decrease in mortality among steroids users as compared to nonusers (OR = 2.0, CI 0.96-4.24). During the period between 1980 and 1989 the reported mortality in TEN cases was approximately 33.4%, which decreased to 27% in the next two decades. There was a nonsignificant difference in mortality in develo- ping countries as compared to developed countries (OR: 0.70, CI 0.32-1.53). Conclusion Corticosteroids have been associated with non significant reduction in the mortality. Apart from this, mortality did not differ over years together in both developing and developed countries. How to cite this article Kaur S, Rajagopalan S, Shafiq N, Dogra S, Srinivasan A, Pandhi P, Malhotra S. Drugs Implicated, Mortality and Use of Corticosteroids in Toxic Epidermal Necrolysis Cases: A Systematic Review of Published Case Reports and Case Series. J Postgrad Med Edu Res 2014;48(3):132-138.

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Z-drugs and Falls: A Focused Review of the Literature

The Senior Care Pharmacist ◽

10.4140/tcp.n.2020.549 ◽

2020 ◽

Vol 35 (12) ◽

pp. 549-554

Author(s):

Nicole Ryba ◽

Rebecca Rainess

Keyword(s):

Primary Outcome ◽

Case Reports ◽

Inappropriate Medication ◽

Case Series ◽

Cochrane Library ◽

Inpatient Setting ◽

Care Hospital ◽

Review Of The Literature ◽

Increased Risk ◽

Risk Of Falls

OBJECTIVE: To provide a focused review of the literature related to the association between exposure to Z-drugs and the risk of falls, especially in the older population. DATA SOURCES: A literature search was conducted using Medline, PsychInfo, and the Cochrane Library database for all clinical trials, case series, and case reports published in English up to May 2020. The search terms used consisted of each Z-drug, including "zolpidem," "zopiclone," "eszopiclone," and "zaleplon," matched with "falls." STUDY SELECTION: The search yielded 295 studies. After review of abstracts, content and references were reviewed, and duplicates removed, a total of 9 articles met inclusion of exposure to at least 1 Z-drug and a primary outcome of falls. DATA EXTRACTION: The American Geriatrics Society 2019 Beers Criteria Update for Potentially Inappropriate Medication Use in Older Adults recommends to avoid using nonbenzodiazepine hypnotics in this patient population because of the risk of adverse events. DATA SYNTHESIS: A majority of the literature suggests an increased risk of falls with exposure to Z-drug use, especially zolpidem. Eight trials examined falls as a primary outcome in non-elderly (n=3) and elderly (n=5) patients in different settings, mostly in an inpatient setting (nursing facility or acute care hospital). CONCLUSION: Exposure to Z-drugs, especially zolpidem, should be evaluated and counseled on continuously as these medications put patients at an increased risk for falls and other complications.

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Z-drugs and Falls: A Focused Review of the Literature

The Senior Care Pharmacist ◽

10.4140/tcp.n.2020.549. ◽

2020 ◽

Vol 35 (12) ◽

pp. 549-554

Author(s):

Nicole Ryba ◽

Rebecca Rainess

Keyword(s):

Primary Outcome ◽

Case Reports ◽

Inappropriate Medication ◽

Case Series ◽

Cochrane Library ◽

Inpatient Setting ◽

Care Hospital ◽

Review Of The Literature ◽

Increased Risk ◽

Risk Of Falls

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Impact of Diabetes Mellitus on Antithrombotic Management Patterns and Long‐Term Clinical Outcomes in Patients With Acute Coronary Syndrome: Insights From the EPICOR Asia Study

Journal of the American Heart Association ◽

10.1161/jaha.119.013476 ◽

2020 ◽

Vol 9 (22) ◽

Cited By ~ 1

Author(s):

Shaoyi Guan ◽

Xiaoming Xu ◽

Yi Li ◽

Jing Li ◽

Mingzi Guan ◽

...

Keyword(s):

Diabetes Mellitus ◽

Acute Coronary Syndrome ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Antiplatelet Agents ◽

Coronary Syndrome ◽

Increased Risk ◽

Antithrombotic Management

Background Long‐term use of antiplatelet agents after acute coronary syndrome in diabetic patients is not well known. Here, we describe antiplatelet use and outcomes in such patients enrolled in the EPICOR Asia (Long‐Term Follow‐up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients in Asia) registry. Methods and Results EPICOR Asia is a prospective, observational study of 12 922 patients with acute coronary syndrome surviving to discharge, from 8 countries/regions in Asia. The present analysis included 3162 patients with diabetes mellitus (DM) and 9602 patients without DM. The impact of DM on use of antiplatelet agents and events (composite of death, myocardial infarction, and stroke, with or without any revascularization; individual components, and bleeding) was evaluated. Significant baseline differences were seen between patients with DM and patients without DM for age, sex, body mass index, cardiovascular history, angiographic findings, and use of percutaneous coronary intervention. At discharge, ≈90% of patients in each group received dual antiplatelet therapy. At 2‐year follow‐up, more patients with DM tended to still receive dual antiplatelet therapy (60% versus 56%). DM was associated with increased risk from ischemic but not major bleeding events. Independent predictors of the composite end point of death, myocardial infarction, and stroke in patients with DM were age ≥65 years and use of diuretics at discharge. Conclusions Antiplatelet agent use is broadly comparable in patients with DM and patients without DM, although patients with DM are more likely to be on dual antiplatelet therapy at 2 years. Patients with DM are at increased risk of ischemic events, suggesting an unmet need for improved antithrombotic treatment. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01361386.

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Safety of Antimicrobials During Pregnancy: A Systematic Review of Antimicrobials Considered for Treatment and Postexposure Prophylaxis of Plague

Clinical Infectious Diseases ◽

10.1093/cid/ciz1231 ◽

2020 ◽

Vol 70 (Supplement_1) ◽

pp. S37-S50 ◽

Cited By ~ 2

Author(s):

Patricia A Yu ◽

Emmy L Tran ◽

Corinne M Parker ◽

Hye-Joo Kim ◽

Eileen L Yee ◽

...

Keyword(s):

Spontaneous Abortion ◽

Case Reports ◽

Case Series ◽

First Trimester ◽

Neonatal Outcomes ◽

Primary Sources ◽

Limited Data ◽

Postexposure Prophylaxis ◽

Increased Risk ◽

Adverse Pregnancy

Abstract Background The safety profile of antimicrobials used during pregnancy is one important consideration in the decision on how to treat and provide postexposure prophylaxis (PEP) for plague during pregnancy. Methods We searched 5 scientific literature databases for primary sources on the safety of 9 antimicrobials considered for plague during pregnancy (amikacin, gentamicin, plazomicin, streptomycin, tobramycin, chloramphenicol, doxycycline, sulfadiazine, and trimethoprim-sulfamethoxazole [TMP-SMX]) and abstracted data on maternal, pregnancy, and fetal/neonatal outcomes. Results Of 13 052 articles identified, 66 studies (case-control, case series, cohort, and randomized studies) and 96 case reports were included, totaling 27 751 prenatal exposures to amikacin (n = 9), gentamicin (n = 345), plazomicin (n = 0), streptomycin (n = 285), tobramycin (n = 43), chloramphenicol (n = 246), doxycycline (n = 2351), sulfadiazine (n = 870), and TMP-SMX (n = 23 602). Hearing or vestibular deficits were reported in 18/121 (15%) children and 17/109 (16%) pregnant women following prenatal streptomycin exposure. First trimester chloramphenicol exposure was associated with an elevated risk of an undescended testis (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.2–28.7). Doxycycline was associated with cardiovascular malformations (OR 2.4, 95% CI 1.2–4.7) in 1 study and spontaneous abortion (OR 2.8, 95% CI 1.9–4.1) in a separate study. First trimester exposure to TMP-SMX was associated with increased risk of neural tube defects (pooled OR 2.5, 95% CI 1.4–4.3), spontaneous abortion (OR 3.5, 95% CI 2.3–5.6), preterm birth (OR 1.5, 95% CI 1.1–2.1), and small for gestational age (OR 1.6, 95% CI 1.2–2.2). No other statistically significant associations were reported. Conclusions For most antimicrobials reviewed, adverse maternal/fetal/neonatal outcomes were not observed consistently. Prenatal exposure to streptomycin and TMP-SMX was associated with select birth defects in some studies. Based on limited data, chloramphenicol and doxycycline may be associated with adverse pregnancy or neonatal outcomes; however, more data are needed to confirm these associations. Antimicrobials should be used for treatment and PEP of plague during pregnancy; the choice of antimicrobials may be influenced by these data as well as information about the risks of plague during pregnancy.

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Effect of oral antiplatelet agents on major bleeding in users of coumarins

Thrombosis and Haemostasis ◽

10.1160/th08-05-0290 ◽

2008 ◽

Vol 100 (12) ◽

pp. 1076-1083 ◽

Cited By ~ 19

Author(s):

Olaf H. Klungel ◽

Patrick C. Souverein ◽

Anthonius de Boer ◽

Tom Schalekamp

Keyword(s):

Major Bleeding ◽

Conditional Logistic Regression ◽

Vitamin K Antagonists ◽

Antiplatelet Agents ◽

Bleeding Risk ◽

Primary Diagnosis ◽

Antiplatelet Drugs ◽

Antiplatelet Drug ◽

Concurrent Use ◽

Increased Risk

SummaryTreatment with vitamin K antagonists (coumarins) is associated with an increased risk of bleeding. In order to elucidate the bleeding risk of users of antiplatelet drugs among users of coumarins, we assessed the odds ratio of major bleeding associated with use of antiplatelet drugs in users of the coumarins acenocoumarol and phenprocoumon. We used data froma Dutch record linkage system, including pharmacy and linked hospitalization records for approximately two million subjects, to conduct a nested case control study in a cohort of new users of coumarins. Cases were patients who were hospitalized with a primary diagnosis of major bleeding while taking coumarin and were matched with up to four control subjects. Conditional logistic regression analysis was used to determine ORs and 95% confidence intervals (CI).We identified 1848 case patients who were matched to 5818 controls. Users of clopidogrel or aspirin showed a significantly increased risk of hospitalization because of major bleeding (OR 2.9, 95% CI 1.2–6.9 and OR 1.6, 95% CI 1.3–1.9, respectively), whereas users of dipyridamole and combinations of antiplatelet drugs showed a strong trend (OR 1.5, 95% CI 1.0–2.3 and OR 1.8, 95 % CI 1.0–3.3, respectively). In all cases, the risks were greater for upper gastrointestinal bleedings than for other bleedings. In conclusion, the use of any antiplatelet drug increases the risk of hospitalization for major bleeding among users of coumarins. Concurrent use of clopidogrel or dipyridamole and coumarins is probably not safer than concurrent use of aspirin and coumarins.

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