Presse Med
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Review Comparative Study
[Perioperative management of new oral anticoagulants].
New oral anticoagulants do represent a major step forward as compared to low molecular weight heparins and vitamin K antagonists. Several issues deserve attention regarding their perioperative management. Three (and very soon four or five) active molecules are available on the market, adding to the major intra- and inter-individual variability, to the high number of drug-drug interactions, and to the interferences of renal function and many other parameters. ⋯ No antidote is approved yet. Scheduled surgery: the safest suggestion is to mimic the perioperative management of vitamin K antagonist, with a 5-day interruption and low molecular weight heparin bridging whenever necessary. Emergency procedures: several suggestions issued from the Groupe d'Intérêt en Hémostase Péri-opératoire are proposed.
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The efficacy of antimalarials, especially hydroxychloroquine (HCQ), in preventing systemic lupus erythematosus (SLE) flares is well demonstrated. However, many studies show that the percentage of SLE patients treated with HCQ remains low. By blocking the toll-like receptor 7 and 9 in plasmacytoid dendritic cells, HCQ inhibits interferon-alpha production which plays a crucial role in SLE pathogenesis. ⋯ During pregnancy and breast-feeding, HCQ continuation is not only allowed but recommended. In conclusion, the risk/benefit ratio of HCQ is excellent. Many now believe that all SLE patients should be offered this treatment.
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The incidence of varicella is low in pregnant women, and estimated around 1/1000 pregnancies. Vaccination is the cornerstone of prevention, but is contraindicated during pregnancy. Varicella is more severe in pregnant women. ⋯ Pregnant women with varicella should receive within 24 hours antiviral treatment based either on valaciclovir or, in case of severe infection, intravenous aciclovir. Both drugs were shown safe during pregnancy, even during the first trimester. Neonates born from mothers who developed varicella between D-5 and D+2 of delivery should also receive as soon as possible specific anti-VZV immunoglobulins.
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Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most popular analgesics administered after open or laparoscopic gastrointestinal surgery. By blocking the cyclooxygenase, they are likely to inhibit fibroblastic response to tissue injury and therefore to impair the healing process. ⋯ Even if not yet supported by high level methodological proofs, cautions should be placed on the use of this pharmaceutical class in this setting. Many questions remain unresolved, especially concerning the influence of NSAIDs cox-2 selectivity, or administration duration.