Managing patients who are taking warfarin and undergoing dental treatment
General guidelines Erythromycin and other macrolide • If patients on warfarin who require antibiotics (for example, azithromycin) dental surgery have an International Macrolide antibiotics interact with warfarin
have liver impairment/high alcohol intake, renal
Normalised Ratio (INR) of below unpredictably and only in certain individuals. Refer to specialist services. 4.0, they can usually receive their Patients should be advised to be vigilant dental treatment in primary care for any signs of increased bleeding.without needing to stop their warfarin or adjust their dose.
patient should be advised to contact the
• The risk of thromboembolism after temporary withdrawal of warfarin
additional INR testing and dose review. therapy outweighs the risk of oral bleeding following dental surgery. Metronidazole Metronidazole interacts with warfarin and • Patients on warfarin may bleed more
should be avoided if possible. If it cannot be
than normal, but bleeding is usually
avoided, the warfarin dose may need to be
controlled with local measures.
reduced by a third to a half, and re-adjusted
Advice to be given to patients
again when the antibiotic is discontinued. Contact the GP or anticoagulant clinic to
Refer to anticoagulation service. Reschedule the procedure when
patient leaflet, Oral Anticoagulant Therapy: INR is less than 4.0. Refer to Important information for dental patients. specialist services for dental Non-steroidal Drug interactions treatment if INR remains above anti-inflammatory drugs 4.0 or control is erratic. Amoxicillin
that amoxicil in interacts with warfarin
causing increased prothrombin time and/or bleeding, but documented cases are
Dental surgery covered by
relatively rare. Patients requiring a course
Drug therapy: if the patient this advice includes: requires analgesia, use
vigilant for any signs of increased bleeding.
Treatment where the INR does not paracetamol. Avoid non-steroidal anti-inflammatories, for example, Clindamycin ibuprofen, aspirin and diclofenac.
Clindamycin is restricted to specialist use
The use of dihydrocodeine should
and should not be used routinely for dental
only be considered for second
infections due to its serious side effects.
line pain relief when other drugs
Treatment where the INR does need
There is a single case report of an interaction
are unsuitable. Codeine has no role in dental analgesia. There is no indication for routine prescribing of antibiotics for dental procedures in this group of patients. See opposite for further information.
All patient safety incidents should be reported to the PCT using local reporting procedures, or directly to the NPSA using the e-form on the NPSA website at www.npsa.nhs.uk. This document was produced with the support of the British Dental Association and advice from the Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology (BCSH) – See www.bcshguidelines.com. The information is based on guidance from UK Medicines Information. Surgical management of the primary care dental patient on warfarin. North West Medicines Information Centre. March 2004.
Evidence-based veterinary dermatology: a systematic review of interventions for Malassezia dermatitis in dogs Amélie Negre*, Emmanuel Bensignor† and Jacques Guillot‡ *Veterinary Clinic, 7 rue de l’Hôtel de Ville, le Châtelet-en-Brie, France†Veterinary Dermatology Referral Service, Veterinary Clinic, Paris and Cesson-Sévigné, Veterinary Hospital, Nantes, France Introduc
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