Management of Apixaban (Eliquis) for Dental Procedures
For most routine dental procedures, you do not need to stop taking Eliquis (apixaban) as the bleeding risk is low and can be managed with local hemostatic measures. 1
Classification of Dental Procedures by Bleeding Risk
Low Bleeding Risk Procedures (No Need to Stop Apixaban)
- Routine dental cleaning
- Simple fillings
- Diagnostic procedures
- Routine dental examinations
- Simple dental extractions with proper local hemostasis
High Bleeding Risk Procedures (May Require Temporary Interruption)
- Multiple tooth extractions
- Complex oral surgery
- Gingival surgery
- Alveolar surgery
- Dental implant placement
Management Algorithm Based on Procedure Risk
For Low Bleeding Risk Dental Procedures:
- Continue apixaban without interruption
- Use local hemostatic measures as needed:
- Gelatin sponges
- Suturing
- Tranexamic acid mouthwash
- Compression with gauze
For High Bleeding Risk Dental Procedures:
For twice daily regimen (standard apixaban dosing):
- Last dose should be on the morning of the day before the procedure 2
- Skip the evening dose before and morning dose on the day of procedure
- Resume apixaban at least 6 hours after the procedure if hemostasis is adequate
For patients with renal impairment:
- Consider longer interruption time if creatinine clearance is reduced
- For CrCl between 30-50 mL/min: consider stopping 3 days before procedure
- For CrCl <30 mL/min: consult with hematology or cardiology
Resumption of Apixaban After Dental Procedures
- For low bleeding risk procedures:
- Resume the same day (evening dose for twice daily regimen) 2
- For high bleeding risk procedures:
- Resume at least 6 hours after the procedure if adequate hemostasis is achieved
- If there is ongoing bleeding, delay resumption and consider venous thromboprophylaxis
Special Considerations
Patients at High Thrombotic Risk
- For patients with recent stroke, pulmonary embolism, or deep vein thrombosis (within 3 months):
- Consider consulting with the prescribing physician before any interruption
- For high bleeding risk procedures requiring interruption, bridging therapy is generally not recommended 2
Local Hemostatic Measures
- Apply direct pressure with gauze for 15-30 minutes
- Consider using hemostatic agents (gelatin sponge, oxidized cellulose)
- Suturing may be necessary for larger extraction sites
- Tranexamic acid mouthwash can be used to reduce post-procedure bleeding
Important Caveats
- Never stop apixaban without consulting the prescribing physician, especially if taken for atrial fibrillation 3
- Stopping apixaban increases stroke risk in patients with atrial fibrillation
- Bridging therapy with heparin is generally not needed when interrupting apixaban
- Patients should be monitored for delayed bleeding, which occurs more frequently in anticoagulated patients 4
- The FDA label for apixaban states that it should be discontinued at least 24 hours prior to procedures with low bleeding risk and 48 hours prior to procedures with moderate to high bleeding risk 3
By following these guidelines, the risk of both bleeding complications and thrombotic events can be minimized during dental procedures for patients taking apixaban.