Should Eliquis (apixaban) be held before a tooth procedure?

Management of Apixaban (Eliquis) for Dental Procedures

For minor dental procedures, including dental extractions, apixaban (Eliquis) should NOT be discontinued as these procedures are classified as minimal bleeding risk. 1

Classification of Dental Procedures

Dental procedures are generally classified as minimal bleeding risk procedures according to the American College of Chest Physicians (ACCP) guidelines. These include:

• Minor dental extractions
• Restorations
• Prosthetics
• Endodontics
• Dental cleanings
• Fillings 1

Evidence-Based Recommendations

For Minor Dental Procedures:

• Continue apixaban without interruption 1
• No need for bridging with heparin 1, 2
• Risk of bleeding is low (approximately 5%) and typically self-limiting 1
• Risk of thromboembolism when stopping anticoagulation unnecessarily is more concerning than the minimal bleeding risk 3

For More Complex Dental Procedures:

If the dental procedure involves extensive oral surgery or has higher bleeding risk:

• For low-to-moderate bleeding risk: discontinue apixaban 24 hours before procedure 4
• For high bleeding risk: discontinue apixaban 48 hours before procedure 4

Practical Management Approach

1. Assess procedure type:

   • For routine dental extractions, cleanings, fillings: continue apixaban
   • For extensive oral surgery: consider temporary interruption based on bleeding risk

2. If continuing apixaban:

   • Consider local hemostatic measures:
     • Tranexamic acid mouthwash (10 mL of 5% solution) 1
     • Local pressure
     • Absorbable gelatin sponges
     • Sutures if needed 5

3. Post-procedure monitoring:

   • Monitor for bleeding every 30 minutes initially 2
   • Avoid strenuous physical activities for 48 hours 2
   • Resume normal activities gradually

Important Considerations

• Patient factors: Renal function impacts apixaban clearance. For patients with impaired renal function, closer monitoring may be warranted 2, 6
• Medication interactions: P-glycoprotein (P-gp) and CYP3A4 inhibitors may increase bleeding risk 4
• Age considerations: Patients over 80 years may have increased bleeding risk 2

Common Pitfalls to Avoid

1. Unnecessary discontinuation: Stopping apixaban for minor dental procedures increases thromboembolism risk without providing clinical benefit 3

2. Bridging with heparin: Not recommended and may increase bleeding risk without reducing thrombotic events 2

3. Inadequate local hemostatic measures: Always ensure proper local hemostasis regardless of anticoagulation status

4. Failure to communicate with dental provider: Ensure dentist is aware of anticoagulation status

The evidence consistently shows that for minor dental procedures, the risk of thromboembolic events from discontinuing anticoagulation outweighs the minimal risk of bleeding complications when continuing therapy 3, 5. Studies have demonstrated negligible bleeding complications in patients on antiplatelet therapy undergoing dental procedures, supporting the safety of continuing anticoagulation 5.