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Mohs Micrographic Surgery: Key Pharmacologic Considerations
Diana Fischer1, Patricia Orlando, Laura Shane-McWhorter
1Intermountain Healthcare, Taylorsville, Utah, USA.
Objective:
To describe Mohs micrographic surgery and evaluate whether direct oral anticoagulants should be withheld in patients with atrial fibrillation (Afib) prior to the procedure and to consider what type of antibiotic prophylaxis should be used.
Setting:
A community setting in which an elderly patient is living independently at home.
Practice Description:
Academic-affiliated internal medicine clinic that cares for adult patients of all ages, including elderly patients living independently in their own home. The practice occasionally consults with geriatric specialty pharmacists to obtain drug information regarding drug therapy.
Practice Innovation:
Identify and assess literature regarding therapeutic issues regarding patients with Afib, whether direct oral anticoagulants should be withheld prior to dermatologic surgery, and what type of antibiotic prophylaxis should be provided prior to the procedure.
Main Outcome Measurements:
Highlight literature that assesses surgical bleeding risk if direct oral anticoagulants are continued, and alternatively, the risk of a thromboembolic event if discontinued; and address antibiotic prophylaxis prior to Mohs micrographic surgery in a patient with Afib.
Results:
In an elderly patient with Afib, a pharmacist should evaluate bleeding risk if direct oral anticoagulants are continued, risk for stroke if anticoagulants are discontinued, and determine appropriate antibiotic prophylaxis prior to Mohs micrographic surgery.
Conclusion:
In patients with Afib treated with direct oral anticoagulants who will have dermatologic surgery, the bleeding risk is usually low, whereas risk of a possible thromboembolic event is high, and antibiotic prophylaxis should be done to prevent infection.
Insights
For patients with atrial fibrillation (Afib) undergoing Mohs surgery, continuing direct oral anticoagulants poses a low bleeding risk but a high thromboembolic risk. Antibiotic prophylaxis is recommended to prevent infection.
Area of Science:
- Dermatology
- Cardiology
- Pharmacology
Background:
- Mohs micrographic surgery is a specialized dermatologic procedure.
- Atrial fibrillation (Afib) management requires careful consideration of anticoagulation therapy.
- Direct oral anticoagulants (DOACs) are commonly used for stroke prevention in Afib.
Purpose of the Study:
- To evaluate the risks and benefits of withholding direct oral anticoagulants (DOACs) in patients with atrial fibrillation (Afib) undergoing Mohs micrographic surgery.
- To determine appropriate antibiotic prophylaxis for patients with Afib undergoing Mohs surgery.
Main Methods:
- Literature review on therapeutic issues in Afib patients undergoing dermatologic surgery.
- Assessment of bleeding risk with DOAC continuation versus thromboembolic risk with DOAC discontinuation.
- Evaluation of antibiotic prophylaxis guidelines for Mohs surgery in Afib patients.
Main Results:
- Continuing DOACs in Afib patients for Mohs surgery presents a low bleeding risk.
- Discontinuing DOACs in Afib patients for Mohs surgery significantly increases the risk of thromboembolic events, such as stroke.
- Pharmacist evaluation of individual patient risks is crucial.
Conclusions:
- The risk of thromboembolic events outweighs the bleeding risk when DOACs are continued for Mohs surgery in Afib patients.
- Antibiotic prophylaxis is essential to prevent surgical site infections.
- Individualized patient assessment by a pharmacist is recommended to optimize management.
