When to use bridging anticoagulation in patients undergoing procedures that require temporary interruption of anticoagulation therapy, such as dental procedures?

From the Guidelines

Bridging anticoagulation is generally not necessary for most dental procedures in patients on anticoagulant therapy. For minor dental procedures, such as cleanings, simple extractions, and root canals, patients can continue their regular anticoagulation without interruption, as the bleeding risk is low and can be managed with local hemostatic measures 1.

Key Considerations

• For patients on warfarin, procedures can safely proceed if the INR is within therapeutic range (typically 2-3) 1.
• For those on direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, dabigatran, or edoxaban, the medication can be continued without interruption for minor procedures 1.
• Bridging with low molecular weight heparin (LMWH) should be reserved only for patients at high thrombotic risk, such as those with mechanical heart valves, recent venous thromboembolism (within 3 months), or atrial fibrillation with recent stroke or multiple risk factors 1.

Management Strategies

• In cases where bridging is necessary, warfarin would be stopped 5 days before the procedure, LMWH (such as enoxaparin 1mg/kg twice daily) started when INR falls below 2.0, stopped 24 hours before the procedure, and resumed 24 hours after the procedure if hemostasis is adequate 1.
• DOACs can typically be stopped 24-48 hours before major procedures and resumed 24-48 hours afterward without bridging 1.

Adjunctive Measures

• Local hemostatic measures, including pressure, sutures, gelatin sponges, tranexamic acid rinses, and avoiding NSAIDs, are important adjuncts to minimize bleeding risk regardless of anticoagulation management strategy 1.

From the FDA Drug Label

Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required

• Bridging anticoagulation is not generally necessary for patients undergoing procedures that require temporary interruption of anticoagulation therapy, such as dental procedures, after stopping apixaban.
• The decision to use bridging anticoagulation should be made on a case-by-case basis, considering the individual patient's risk of thromboembolism and bleeding.
• Apixaban should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established 2.

From the Research

Bridging Anticoagulation in Patients Undergoing Procedures

• Bridging anticoagulation is used to maintain functional anticoagulation in patients who require temporary interruption of chronic oral anticoagulant (OAC) therapy for an elective surgical or invasive procedure 3.
• The decision to use bridging anticoagulation is based on the patient's and procedure's thromboembolic and bleeding risks 4.
• Certain procedures, such as dental, endoscopic, and cutaneous procedures, can be completed without discontinuing OAC, but most procedures with a high bleeding risk will necessitate temporary discontinuation of OAC 3.

Procedures that Require Bridging Anticoagulation

• Procedures with a high bleeding risk, such as major surgeries, may require bridging anticoagulation 3.
• Minor procedures, such as dental procedures, may not require bridging anticoagulation if the patient is at low risk of thromboembolism 5.
• Patients with mechanical heart valves or other high-risk conditions may require bridging anticoagulation for non-high-bleeding risk procedures, such as minor surgery and invasive procedures 6.

Choice of Bridging Anticoagulant

• Low-molecular-weight heparin (LMWH) is often considered the medication of choice for bridging anticoagulation due to its ease of use and lack of need for coagulation monitoring or dose adjustment 5.
• LMWH has been shown to be safe and effective for bridging anticoagulation in patients undergoing various procedures, including those with mechanical heart valves 6.
• Unfractionated heparin may also be used for bridging anticoagulation, but it requires more frequent monitoring and dose adjustments compared to LMWH 6.

Management of Bridging Anticoagulation

• The management of bridging anticoagulation should be individualized based on the patient's and procedure's risks 4.
• The timing of bridging anticoagulation should be carefully planned to minimize the risk of thromboembolism and bleeding 3.
• Patients should be closely monitored for signs of bleeding or thromboembolism during and after the procedure 7.