How long should Eliquis (apixaban) be held before a dental extraction?

Management of Apixaban (Eliquis) for Dental Extractions

For minor dental procedures, including dental extractions, apixaban should NOT be discontinued as these procedures are classified as minimal bleeding risk, according to the American College of Chest Physicians guidelines. 1

Rationale for Continuing Apixaban During Dental Procedures

• The American College of Chest Physicians recommends continuing apixaban without interruption for minor dental procedures, with a low risk of bleeding (approximately 5%) that is typically self-limiting 1
• This represents a shift from older practices that often recommended discontinuation of anticoagulants before dental procedures
• Continuing anticoagulation helps prevent potentially dangerous thromboembolic events while posing minimal bleeding risk

Local Hemostatic Measures

When performing dental extractions while continuing apixaban:

• Use local hemostatic measures such as:
  • Tranexamic acid mouthwash (10 mL of 5% solution) 1
  • Gelatine sponge placement in extraction sockets
  • Suturing as needed
  • Pressure pack with gauze for 30-60 minutes post-procedure

Post-Procedure Monitoring

• Monitor for bleeding every 30 minutes initially after the procedure 1
• Avoid strenuous physical activities for 48 hours after the procedure 1
• Instruct patients to contact their provider if they experience prolonged or excessive bleeding

Special Considerations

If Discontinuation Is Deemed Necessary (High Bleeding Risk Cases)

In rare cases where the bleeding risk is exceptionally high and discontinuation is considered:

• According to the FDA label, apixaban should be discontinued at least 24 hours prior to procedures with a low risk of bleeding 2
• For procedures with moderate to high bleeding risk, discontinuation should occur at least 48 hours prior 2
• Resumption should occur as soon as adequate hemostasis has been established 2

Dosing Considerations

• Standard dosing of apixaban is 5 mg twice daily, with dose reduction to 2.5 mg twice daily for patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1, 2
• Patients with dose adjustments should follow the same recommendations regarding continuation during dental procedures

Evidence Supporting Continuation of Anticoagulants

Multiple studies support the safety of continuing anticoagulation during dental procedures:

• Research has demonstrated that dental extractions can be safely performed without discontinuation of antiplatelet therapy when appropriate local hemostasis is provided 3, 4
• Similar findings have been reported with direct oral anticoagulants like rivaroxaban, showing no significant difference in bleeding complications between anticoagulated patients and controls 5
• Modern local hemostatic techniques such as leukocyte-platelet-rich fibrin (L-PRF) and advanced platelet-rich fibrin (A-PRF+) have shown effectiveness in reducing bleeding risk in patients on antiplatelet therapy 6

Pitfalls to Avoid

• Unnecessarily discontinuing apixaban before dental extractions, which increases thromboembolic risk without providing significant benefit
• Failing to use appropriate local hemostatic measures during and after the procedure
• Overlooking patient comorbidities like hypertension and diabetes that may increase bleeding risk 6
• Neglecting to provide clear post-procedure instructions to patients regarding bleeding management