Use of aspirin/warfarin seems safe for derm surgery patients

National report - When it comes to the issue of perioperative management of existing anticoagulant and antiplatelet therapy in patients undergoing cutaneous procedures, results of a mail survey indicate most British dermatologists are continuing those medications and without untoward consequences, reports Claudia V. DeGiovanni, M.D.

"It was reassuring to find in our study that consistent with the studies and recommendations published in the dermatology literature, most dermatologists are keeping their patients on warfarin and aspirin whenever possible and without encountering long-term sequelae from hemorrhagic complications. However, it would probably be helpful to have national guidelines that could be easily accessed by clinicians," Dr. DeGiovanni tells Dermatology Times.

Dr. DeGiovanni is currently a registrar at Brighton and Sussex University Hospitals NHS Trust, UK. She undertook the study as a registrar at Worthing and Southlands NHS Trust in collaboration with Peter Coburn, M.D., consultant, after being asked to review the dermatology department's patient information leaflets for surgical procedures.

"I found variability in the practices of the members within our department and did some literature research that identified several papers published on this topic, including a fairly recent article by Stables and Lawrence (Clin Exp Dermatol. 2002;27:432-435) that suggested guidelines," Dr. DeGiovanni says.

The variance within their own department led the dermatologists to conduct a survey of members of the British Association of Dermatology. A questionnaire was sent to the 681 members asking them to indicate their personal policies about stopping aspirin and warfarin preoperatively for various procedures (punch biopsy, excision, flap, graft) and to describe any complications encountered in patients on these medications according to whether or not they had been stopped.

Survey results

A total of 175 (25.7 percent) questionnaires were returned and nearly three-fourths of those were consultants.

With the results summarized by drug and procedure, rates of discontinuation generally increased with increasing extent of the procedure and were higher for aspirin than for warfarin. For patients undergoing punch biopsy, 4.6 percent of respondents discontinued warfarin and 7.6 percent stopped aspirin. Nearly 60 percent of the responding dermatologists stopped aspirin in patients having a graft and almost 25 percent stopped warfarin for that type of procedure.

Interestingly, the results also showed that when warfarin or aspirin were stopped, the published recommendations for withdrawal were often not followed. Aspirin was stopped for between one and 14 days prior to surgery with a median of seven days, and warfarin was stopped one to four days preoperatively with a median of three days.

"Stables and Lawrence recommended stopping aspirin for 10 days and warfarin for three days and ensuring the INR is less than 2.5. Only 13 percent of the 55 dermatologists who stopped aspirin did so for the recommended 10 days, and among the 24 who stopped warfarin, only 24 percent ensured the INR was less than 2.5 and only 38 percent stopped it for the recommended duration," Dr. DeGiovanni says.

Several surgical complications were encountered among the patients who continued on their medications, including five hematomas, six prolonged bleeds (>1 hour), a graft failure and a case of flap necrosis. Consistent with literature reports, there were no long-term complications. Among the patients who stopped their medications, six went on to develop a thromboembolic event over the next year and at least one of those individuals suffered long-term sequelae.

"We did not get as much detailed information as we would have liked about the complications that occurred. However, for both aspirin and warfarin, one patient each who stopped those medications experienced a cerebrovascular accident, and we are aware that one of those individuals has permanent consequences," Dr. DeGiovanni says.