ARTICLE
Auteur(s) : Deemesh Oudit, Ali Soueid, Gary Ross,
Hymayen Khan, Ali Jama
Department of Plastic and Reconstructive Surgery Lancashire
Teaching Hospitals Royal Preston Hospital, Lancashire, England
accepté le 2 Mars 2007
Significant proportions of patients who present for dermatological
surgical procedures take aspirin or other anti-platelet agents
(clopidogrel or non-steroidal anti-inflammatory drugs) or are on
anticoagulants (e.g. warfarin) [1, 2]. The prescribed uses of these
agents are increasing [3]. Their use encompasses prophylaxis
against thrombotic events from cardiovascular events or in
prosthetic valve replacements or as analgesia in chronic conditions
such as arthritis. The consequences of discontinuing these
medications, even for a short duration of time, can lead to severe
and possibly permanent morbidities or can even lead to mortality.
It has been shown that the continuation of anti-platelet agents and
anticoagulant therapy prior to cardiac [4], abdominal, thoracic,
ocular, urological and gynaecological procedures can result in an
increase in postoperative bleeding problems [2, 5]. Therefore,
these drugs are temporarily stopped in patients presenting for the
above procedures. Reports in the literature have been contradictory
with regards to the perioperative management of these groups of
patients presenting for dermatological procedures [1, 3, 6, 7].
With the increasing drive towards evidence-based medicine we felt
it would be helpful to explore the current practise with regards
the use of anti-platelet or anti-coagulant agents in dermatological
practise when involving excision of skin lesions. Therefore, we
undertook a survey to determine the current practices of consultant
dermatologists to investigate the spectrum of practice amongst
dermatologists and dermatological surgeons and to determine whether
there was uniformity of practice in this regard and whether the
modes of practice differed from those outlined in the literature.
Materials and methods
We undertook a postal questionnaire survey to all of the
dermatological surgeons in the United Kingdom to determine whether
they have a policy on the perioperative management of patients on
non-steroidal anti-inflammatory agents (NSAIDS), anti-platelet
agents and anticoagulants and also to obtain their opinion on how
these patients should managed in the perioperative period. This
study was undertaken in May, 2003 and was carried out over a
6-month period. The list and working addresses of the
dermatologists were obtained from a list prepared and published by
the British Association of Dermatologists. A questionnaire was
designed and posted to each of the Consultants individually table 1. The responses were all anonymous. The
results were then subjected to analysis.
Table 1 A summary of the questionnaire submitted
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Number of years in practice:
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Do you have a policy regarding the perioperative use of:
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- Aspirin
- NSAIDS
- Clopidogrel
- Warfarin
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If the answer is YES to the above, do you advise the
discontinuation of drugs for minor cutaneous surgery?
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- Asprin
- NSAIDS
- Clopidogrel
- Warfarin
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Do you advise the discontinuation of drugs for facial
surgery?
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- Asprin
- NSAIDS
- Clopidogrel
- Warfarin
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Do you advise the discontinuation of drugs for major
surgery?
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- Asprin
- NSAIDS
- Clopidogrel
- Warfarin
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Is your practice based on:
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- Published studies
- Local unit policy
- Personal preference
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Is your management of patients taking Aspirin dose
dependent?
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What is the maximum INR value you consider to be safe
pre-operatively for:
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- Minor surgery
- Major surgery
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Results
185 questionnaires were sent of which 92 (50%) were returned within
six months. Since the responses to the questionnaires were
anonymous, it was not possible to send reminders to the
non-responders. Respondents were asked whether their practice was
based on published studies, local unit policy and/or personal
preference. The three responses were not mutually exclusive and the
respondents could have answered in the affirmative to one or more
of the options. Overall, most respondents (61%) stated that their
practice was primarily based on personal preference and 30% stated
that it was based on the local Unit policy. Only 34% of the
Consultants based their practice on evidence-based medicine. The
patterns of practice amongst dermatological surgeons in the UK are
outlined below. Overall, in terms of the individual drugs
considered, most consultants reported having a policy for the
perioperative management of patients on warfarin (73%) and aspirin
(64%). However, only 31% of the respondents reported having a
policy for NSAIDS and 28% had a policy for the perioperative
management of patients on clopidogrel. The respondents were further
questioned on the usage of these drugs for minor cutaneous and
facial surgery. Although most of the facial procedures involve
excision of cutaneous lesions, these were considered in a separate
category since bleeding complications are less well tolerated both
by the clinician and by the patient. For minor cutaneous surgery
aspirin was the most commonly discontinued drug (34%) by
dermatological surgeons, followed by warfarin (28%), NSAIDS (11%)
and clopidogrel (11%). It was noted that for all of the drugs
considered, they were more commonly stopped prior to facial
procedures than for minor cutaneous operations (figure 1).
Aspirin
Seven days was the most common time preoperatively for the
discontinuation of aspirin for both minor and facial dermatological
surgical operations. For minor cutaneous operations the mean time
was found to be 6.27 days preoperatively and for facial operations,
6.55 days preoperatively (figure 2). Only 7% of the
respondents stated that their management of patients on aspirin was
dose-dependent.
Warfarin
Although the range of time for the discontinuation of warfarin
varied significantly, the most common time for discontinuation for
all types of dermatologic surgical operations was found to be 2
days preoperatively (figure 3). The maximum
preoperative INR value which respondents considered safe for minor
surgery ranged from 1.5-4.5 with a mean of 2.63 (sd +/– 0.59) and a
mode of 2.5.
NSAIDS
For NSAIDS, the most common time for discontinuation was 7 days
preoperatively for minor cutaneous procedures with a mean time of 6
days. However, for facial operations, there was a divided opinion
as to when NSAIDS should be discontinued preoperatively, with 2 and
7 days being the most common response. The mean time however, for
discontinuing NSAIDS preoperatively was noted to be 5.63 days (figure 4).
Clopidogrel
With regards to clopidogrel, the most common time preoperatively
for discontinuation was found to be 2 days for minor dermatological
operations and 3 days for facial procedures. The mean time for
discontinuing clopidogrel preoperatively was 5.2 days for minor
cutaneous and 5.25 days for facial procedures (figure 5).
Discussion
In this survey we have found that the practice of only one-third of
respondents was evidence-based, somewhat comparable to the results
from a similar survey of plastic surgeons, of whom only a quarter
used evidence-based practice [8].
The proportion of respondents having policies varied with the
type of drug. Most of them reported having a policy for the
perioperative management of patients on warfarin and aspirin; fewer
of them, however, had a policy for NSAIDS or clopidogrel. The
policies for warfarin, aspirin and NSAIDS are present in similar
proportions in plastic surgical units but more than double of the
dermatological units have policies for the use of clopidogrel
compared with plastic surgical units [8]. In our survey, the scope
of dermatological surgical procedures was divided into two groups:
minor cutaneous surgery and facial procedures. Although a large
proportion of minor cutaneous surgery involves facial surgery,
postoperative bleeding in facial procedures can be perceived to be
more devastating to the patient. Hence, facial surgery was
considered in a separate category in this study. A larger
proportion of dermatological surgeons discontinue aspirin and
warfarin compared to NSAIDs and clopidogrel and more of the
respondents reported that they would discontinue these drugs for
facial procedures than for minor ones (figure 1). We speculate
that this may be due to factors such as increased awareness of the
consequences of complications in procedures on the face like
interference with cosmesis and the increased risk of bleeding in
the face because of its highly vascular nature.
Of the respondents who discontinued these drugs preoperatively,
notable variations in practice were noted for the discontinuation
of aspirin, NSAIDS and clopidogrel. However, practice with regards
to warfarin was more consistent, which may reflect a more
widespread understanding of the pharmacological aspects of this
drug compared to the rest. It is encouraging that the most common
time reported for the discontinuation of warfarin was 2 days
preoperatively for both minor cutaneous and facial procedures and
the most common maximum International Normalised Ration (INR) value
for proceeding with surgery was found to be 2.5, which is in
keeping with previously reported guidelines [1, 9].
In this study, the most common time for the discontinuation of
aspirin was found to be 7 days. Aspirin permanently inhibits
cyclo-oxygenase activity and thromboxane A2 synthesis within
platelets and this effect lasts for the lifespan of the platelet
(7-10 days) [10] and for this reason Goldsmith et al. recommended
discontinuing aspirin 7-10 days preoperatively [1].
Only a minority of the respondents discontinue NSAIDs for minor
and facial procedures, with a mean of 6 days pre-operatively.
NSAIDs bind reversibly to cyclo-oxygenase; therefore, their effect
is only transient and lasts only while they are still present in
significant amounts in the systemic circulation. Goldsmith et al.
recommended that it is only necessary to discontinue NSAIDs 24
hours preoperatively [1]. The discontinuation of NSAIDs for a
prolonged period of time by some dermatologists and from a previous
similar study, by plastic surgeons, clearly indicates a lack of the
understanding their pharmacology [8]. Fortunately the morbidity
associated with stopping NSAIDs in terms of severe complications is
much less compared with aspirin, clopidogrel and warfarin.
Again only a minority of the respondents discontinued
clopidogrel and again with a mean of 5 days, which differs from the
recommendations of the manufacturers who suggest that the drug
needs to be stopped 7 days preoperatively if its anti-platelet
effects are not desirable [3]. Clopidogrel is a relatively recent
inhibitor of adenosine diphosphate (ADP)-induced platelet
aggregation, used to reduce the risk of atherothrombolic events
such as in patients who suffered recent myocardial infarctions or
cerebral vascular accidents and there is perhaps less familiarity
with it as compared to aspirin or warfarin, which might explain our
findings.
The perceived benefits of discontinuing these drugs
preoperatively must be weighed against their anti-thrombotic
benefits. A survey of the literature suggests that there are no
significantly increased benefits from discontinuing these drugs
preoperatively for cutaneous excisional surgery [3, 5, 6, 11, 12].
Otley et al reported that severe complications in patients on
warfarin or anti-platelet agents occurred in 1.6% of cases which
was not significantly increased compared to complications in
control subjects [8] and no statistically significant reduction in
the rates of severe complications in patients who discontinued
these drugs preoperatively was found [11]. The discontinuation of
these drugs increases the risks of thrombotic complications which
can have significant morbidity and may even result in death [7, 11,
12]. The risks of thrombotic complications occurring in patients
discontinuing warfarin include potentially debilitating and even
fatal conditions such strokes, myocardial infarctions and emboli
(pulmonary or retinal artery) [8, 9, 13]. Several reports in the
literature have shown that there is no significantly increased risk
of haemorrhagic complications compared to controls and that these
were not significantly decreased by discontinuation of these drugs,
based on cutaneous studies [3, 5, 6, 11, 12].
In summary, a review of the literature has revealed that
discontinuing these drugs in patients presenting for excisional
cutaneous surgery has no significant benefits and may unnecessarily
expose these patients to thrombotic risks, which could result in
significant morbidity, although these are not quantifiable at
present.
At present, there are no established policies or standard
guidelines in the practice of dermatological surgery in the UK in
relation to the perioperative management of patients on
anti-platelet agents and anti-coagulants. In fact, there appear to
be variations in the practice amongst dermatological surgeons, and
the findings of this study mirror the findings of the authors with
a similar survey about the use of these agents by plastic surgeons.
Although practice is influenced by the individual indication for
usage of these drugs, there is a need for practice to be
standardized by the development of guidelines and policies. This is
necessary since a significant proportion of patients presenting for
excision of skin lesions are on at least one of these agents. A
significant workload of dermatologists, plastic surgeons, general
surgeons and general practitioners involves excising skin lesions
and we feel it is important of national regulatory bodies in
Europe, to publish clear evidence-based guidelines about the use of
anti-platelet or anti-coagulant medications in cutaneous surgery.
These guidelines would be helpful in the management of most
patients, and would also reduce the risk of successful litigation
as a result of morbidity. Individual complex cases may require the
advice of a haematologist or a specialist physician.
Acknowledgements
Financial support: none.
Conflict of interest: none.
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