Sir, new oral anti-coagulant (NOAC) drugs have become increasingly popular. Recently, we have seen a series of three patients who were taking NOAC drugs, had extractions under local anaesthesia and returned to casualty due to extensive bleeding.

NOAC agents are often preferred to warfarin as they are easier to manage from a patient perspective. However, how easy are they to manage from the clinician's perspective?

These patients were either taking rivaroxaban or apixaban. Two patients were managed effectively with local haemostatic agents. One patient required admission for three days and received a two-unit blood transfusion.

In emergency situations, it is challenging to reverse the effect of these drugs as they cannot be reliably monitored. Comparatively, warfarin can be monitored via an international normalised ratio (INR) and reversed with vitamin K.

We recommend liaison with the clinician managing the patient's anticoagulation and discussion about stopping the NOAC drug 48 hours prior to the procedure, as suggested in the National Health Service (NHS) guidelines. We also encourage referral of these patients to a hospital setting, as necessary.

We are keen to hear from other clinicians with their experiences.

1. Oxford