Does an 80-year-old male with a history of Percutaneous Coronary Intervention (PCI), Atrial Fibrillation (Afib), and Cerebrovascular Accident (CVA) on Eliquis (Apixaban) need to hold Eliquis for a tooth extraction?

Management of Apixaban for Tooth Extraction in an 80-Year-Old Patient with Atrial Fibrillation and History of CVA

For this 80-year-old male with history of PCI, atrial fibrillation, and previous CVA on Eliquis (apixaban), tooth extraction can be safely performed WITHOUT interruption of anticoagulation therapy.

Rationale for Continuing Apixaban

The decision to continue apixaban during dental procedures is based on:

1. Bleeding Risk vs. Thrombotic Risk Assessment:

   • Tooth extraction is considered a low bleeding risk procedure
   • Patient has high thrombotic risk (atrial fibrillation with history of CVA)
   • Temporary discontinuation of anticoagulation significantly increases stroke risk

2. Evidence Supporting Continuation:

   • Recent studies demonstrate that tooth extractions can be safely performed without interrupting DOACs when appropriate local hemostatic measures are implemented 1
   • The risk of serious bleeding complications with continued anticoagulation is low and manageable with local measures 2

Recommended Protocol

Before the Procedure:

• Confirm the patient is taking the appropriate dose of apixaban (likely 5mg BID, or 2.5mg BID if he meets dose reduction criteria)
• No need to skip any doses before the procedure
• Schedule the extraction approximately 6-7 hours after the morning dose of apixaban to minimize peak drug concentration 1

During the Procedure:

• Use local hemostatic measures:
  • Fibrin sponge placement in extraction socket
  • Silk sutures
  • Tranexamic acid-soaked gauze compression

After the Procedure:

• Continue regular apixaban dosing without interruption
• Provide clear post-extraction care instructions
• Avoid NSAIDs for pain control (increased bleeding risk)
• Use acetaminophen for pain management

Important Considerations

1. High Thrombotic Risk: This patient has multiple risk factors (age >80, history of PCI, atrial fibrillation, and previous CVA) that significantly increase his thrombotic risk if anticoagulation is interrupted 3

2. FDA Label Guidance: The FDA label for apixaban indicates that it should be discontinued at least 24 hours prior to procedures with low bleeding risk 4. However, more recent evidence and guidelines suggest that for dental procedures specifically, continuation is safe and preferred.

3. Perioperative Management Guidelines: While the French Working Group on Perioperative Hemostasis guidelines suggest discontinuation for some procedures, they classify dental extractions as low hemorrhagic risk procedures 3

4. Practical Insights: The most recent evidence from Praxis Medical Insights indicates that for minor dental procedures, apixaban can be continued without interruption 5

Potential Complications and Management

If bleeding occurs despite preventive measures:

• Apply additional local hemostatic agents
• Extended compression with tranexamic acid-soaked gauze
• Additional suturing if necessary

Summary

The benefits of continuing apixaban for this high-risk patient outweigh the manageable bleeding risks associated with tooth extraction. The procedure can be safely performed with appropriate local hemostatic measures without interrupting anticoagulation therapy, thereby avoiding the potentially catastrophic risk of thrombotic events that could result from temporary discontinuation.