For a patient on Xarelto (rivaroxaban), how long before and after a tooth extraction should they stop taking this medication?

From the Guidelines

For patients on Xarelto (rivaroxaban), it is recommended to stop taking the medication 2 days before a tooth extraction and resume it 24 hours after the procedure, if adequate hemostasis has been achieved, as suggested by the study 1. This approach is based on the drug's elimination half-life and its dependence on renal clearance. The decision to stop or resume the medication should always be individualized based on the patient's specific bleeding risk and the complexity of the dental procedure. For simple extractions in patients with low bleeding risk, skipping just one dose may be sufficient, while more complex procedures or patients with higher bleeding risk may require stopping the medication 48 hours before. It's crucial that patients consult with both their dentist and the prescribing physician before making any changes to their anticoagulation regimen. The temporary interruption balances the risk of bleeding during the procedure against the risk of thrombotic events from medication discontinuation. After the extraction, local hemostatic measures like pressure, sutures, or hemostatic agents may be used to control bleeding before resuming anticoagulation, as noted in the study 1. Some key points to consider include:

• The patient's renal function, as it affects the drug's elimination half-life
• The type of surgery, with more complex procedures requiring longer interruption of the medication
• The patient's bleeding risk, with those at higher risk requiring more cautious management
• The importance of consulting with both the dentist and the prescribing physician before making any changes to the anticoagulation regimen, as emphasized in the study 1. Overall, the goal is to minimize the risk of bleeding while also preventing thrombotic events, and this can be achieved by carefully managing the interruption and resumption of Xarelto, as suggested by the studies 1.

From the FDA Drug Label

If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings and Precautions (5. 2)] . XARELTO should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established, noting that the time to onset of therapeutic effect is short [see Warnings and Precautions (5.1)] .

The patient on Xarelto should stop taking the medication at least 24 hours before tooth extraction to reduce the risk of bleeding. Xarelto should be restarted after the procedure as soon as adequate hemostasis has been established 2.

From the Research

Stopping Xarelto (Rivaroxaban) Before Tooth Extraction

• There is no clear consensus on the exact duration for which Xarelto should be stopped before a tooth extraction, as the decision may depend on various factors including the patient's overall health, the type of extraction, and the dentist's or doctor's professional judgment 3, 4, 5, 6, 7.
• Some studies suggest that dental treatment, including tooth extraction, may be safely delivered without stopping Xarelto, while others recommend stopping the medication for a certain period before the procedure 4, 5.
• One study found that stopping Xarelto for more than 2 days before tooth extraction may reduce the risk of bleeding, but the evidence is not conclusive 5.

Resuming Xarelto After Tooth Extraction

• The decision to resume Xarelto after tooth extraction should be made in consultation with the patient's doctor or dentist, taking into account the patient's individual risk factors and the type of extraction performed 3, 4, 5, 6, 7.
• Some studies suggest that Xarelto can be resumed shortly after tooth extraction, while others recommend waiting for a certain period to minimize the risk of bleeding 4, 5.
• Close monitoring of the patient's condition after tooth extraction is essential to prevent excessive bleeding, especially in the first week after the procedure 6, 7.

Bleeding Risk Associated with Xarelto and Tooth Extraction

• Several studies have reported an increased risk of bleeding after tooth extraction in patients taking Xarelto, although the bleeding episodes were generally manageable 3, 5, 6, 7.
• The risk of bleeding may be higher in patients taking Xarelto compared to other anticoagulants, such as dabigatran or edoxaban 7.
• Factors that may increase the risk of bleeding after tooth extraction in patients taking Xarelto include the number of teeth extracted, the need for flap elevation, and the performance of osteotomy 5.