An 87-year-old woman weighing 70 kg who is taking apixaban (Eliquis) 2.5 mg twice daily for atrial fibrillation needs a dental tooth extraction; how should she be switched to unfractionated heparin?

Do NOT Switch to Heparin for Dental Extraction

For this 87-year-old woman on apixaban 2.5 mg twice daily, you should simply stop the apixaban 1-2 days before the tooth extraction and resume it 6-24 hours after the procedure—bridging with heparin is NOT recommended and may actually increase bleeding risk. 1

Why No Heparin Bridging?

The French GIHP guidelines explicitly state that preoperative bridging by UFH or LMWH is not recommended for patients on direct oral anticoagulants (DOACs) undergoing invasive procedures 1. This recommendation is based on evidence showing that bridging with heparins in atrial fibrillation patients on anticoagulants increases bleeding risk without reducing thromboembolic risk 1.

The FDA label for Eliquis reinforces this: "Bridging anticoagulation during the 24 to 48 hours after stopping ELIQUIS and prior to the intervention is not generally required" 2.

Specific Management Protocol for This Patient

Pre-Procedure:

Dental extraction is classified as a LOW bleeding risk procedure, so:

• Stop apixaban on the morning of the day before the extraction (since she takes it twice daily, this means skipping 2 doses) 1
• The last dose should be approximately 24 hours before the procedure 2
• No laboratory monitoring needed 1
• No heparin bridging 1, 2

Post-Procedure:

• Resume apixaban at least 6 hours after the extraction once hemostasis is achieved 1, 2
• Since she's on twice-daily dosing, restart the evening of the same day if bleeding is controlled 1
• Use local hemostatic measures (cellulose, collagen, sutures) as needed 3

Important Clinical Context

Why This Patient is on 2.5 mg Dose:

She's likely on the reduced dose (2.5 mg twice daily instead of 5 mg) because she meets at least 2 of these criteria:

• Age ≥80 years (she's 87) ✓
• Weight ≤60 kg (she's 70 kg, so doesn't meet this)
• Serum creatinine ≥1.5 mg/dL (unknown, but possible at age 87)

Evidence Supporting No Bridging:

A prospective study of tooth extractions in anticoagulated patients showed no major bleeding events when DOACs were timed appropriately around the procedure without discontinuation or bridging 3. The key is timing the extraction during the lowest plasma concentration.

Common Pitfalls to Avoid

1. Don't reflexively bridge "high-risk" AF patients—the stroke risk during a 24-48 hour interruption is extremely low, while bridging increases bleeding risk
2. Don't check INR—it's not useful for monitoring apixaban 2
3. Don't stop the medication too early—apixaban has a short half-life (7-8 hours), so stopping 3-5 days before is excessive for a simple extraction
4. Don't delay resumption unnecessarily—once local hemostasis is achieved, anticoagulation should restart to minimize thrombotic risk

Alternative Approach (If Absolutely Necessary)

If the dentist insists on performing the extraction without stopping apixaban (which some recent protocols support for simple extractions 3), this can be done by:

• Scheduling the extraction 8 hours after her last dose (trough level)
• Using meticulous local hemostatic measures
• This approach showed no major bleeding in clinical trials 3

However, the safest and most guideline-concordant approach remains the 24-hour interruption without heparin bridging.