Is it appropriate to decrease apixaban (Apaxiban) 5mg twice daily (BID) to 2.5mg BID in a patient with atrial fibrillation (fib) and stroke history who is experiencing persistent clot expulsion from a dental socket due to a recently avulsed tooth?

From the Guidelines

I do not recommend decreasing the apixaban dose from 5mg BID to 2.5mg BID for this patient with atrial fibrillation and history of stroke who is experiencing bleeding from a tooth socket. Instead, the patient should maintain their prescribed anticoagulation dose and seek prompt dental care. Local measures should be used to control the bleeding, including applying pressure to the area with gauze for 15-20 minutes, using tranexamic acid mouthwash if available (by dissolving a 500mg tablet in water and rinsing for 2 minutes four times daily), or applying a tea bag containing tannic acid to the socket. The patient should avoid hot liquids, alcohol, smoking, and strenuous activity which can increase bleeding. Reducing the apixaban dose without medical supervision could significantly increase stroke risk, as the 5mg BID dosing was likely carefully selected based on the patient's stroke and bleeding risk factors, as outlined in the 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation 1. The current bleeding, while concerning, is likely manageable with local measures and dental intervention rather than systemic dose adjustment. If bleeding becomes severe or uncontrollable, the patient should seek emergency care immediately. It's worth noting that the ARISTOTLE trial compared apixaban (5 mg bid) with warfarin and found that apixaban was superior to warfarin in preventing stroke and systemic embolism and produced less bleeding 1. Therefore, maintaining the current dose of apixaban is crucial to minimize the risk of stroke and other thromboembolic events in this patient. The patient's renal function should also be considered, as apixaban dose adjustment is recommended for patients with creatinine clearance (CrCl) 15-50 mL/min, but this is not the case here, as the patient's CrCl is not mentioned to be below 50 mL/min 1.

From the FDA Drug Label

The recommended dose of apixaban tablets for most patients is 5 mg taken orally twice daily. The recommended dose of apixaban tablets is 2. 5 mg twice daily in patients with at least two of the following characteristics: • age greater than or equal to 80 years • body weight less than or equal to 60 kg • serum creatinine greater than or equal to 1.5 mg/dL

The patient's situation with a fallen out tooth and spitting out clots does not directly match any of the characteristics listed for dose reduction. Dose reduction is not explicitly recommended for bleeding due to a tooth extraction.

• The primary concern is the patient's underlying condition of nonvalvular atrial fibrillation, which requires anticoagulation to reduce the risk of stroke and systemic embolism.
• Decreasing the dose to 2.5mg BID without a clear indication from the drug label may increase the risk of thrombotic events 2. It is recommended to consult with the patient's healthcare provider for guidance on managing the patient's anticoagulation therapy in this situation.

From the Research

Apixaban Dosage Adjustment

• The patient is currently taking apixaban 5mg BID for atrial fibrillation and stroke prevention, and is experiencing bleeding due to a fallen out tooth 3, 4.
• There is no direct evidence to support decreasing the apixaban dosage to 2.5mg BID in this specific situation.
• However, studies have shown that apixaban has a lower risk of bleeding compared to warfarin, and that the risk of bleeding is associated with factors such as older age, prior hemorrhage, and decreased creatinine clearance 5, 6.

Bleeding Risk Management

• The ARISTOTLE trial found that apixaban was associated with a lower rate of major hemorrhage and fewer intracranial hemorrhages compared to warfarin 5.
• A history of bleeding is associated with a higher risk of major bleeding, but the beneficial effects of apixaban over warfarin remain consistent regardless of bleeding history 6.
• The role of apixaban in venous and arterial thromboembolic disease has been established, with apixaban being superior to aspirin and warfarin in preventing stroke and systemic embolism in patients with atrial fibrillation 7.

Considerations for Dosage Adjustment

• The decision to adjust the apixaban dosage should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history 3, 4.
• It is essential to weigh the benefits of anticoagulation against the risks of bleeding, and to consider alternative management strategies, such as closer monitoring of the patient's bleeding status or the use of local hemostatic measures 5, 6.