How many days should Eliquis (apixaban) be held before tooth extraction?

Management of Apixaban (Eliquis) Before Tooth Extraction

For tooth extraction, which is considered a minor dental procedure with minimal bleeding risk, apixaban should NOT be discontinued as per the American College of Chest Physicians guidelines. 1

Evidence-Based Recommendations

The most recent guidelines from the American College of Chest Physicians (2022) specifically classify minor dental procedures, including dental extractions, as minimal bleeding risk procedures that do not require discontinuation of apixaban 1. This represents a significant update from older recommendations that suggested longer discontinuation periods.

For these procedures:

• Continue apixaban without interruption
• Implement local hemostatic measures (such as tranexamic acid mouthwash)
• Monitor for bleeding every 30 minutes initially after the procedure

Alternative Approach (If Discontinuation Is Deemed Necessary)

If the clinician determines that discontinuation is necessary due to specific patient factors or more complex extractions, the FDA label and French Working Group on Perioperative Hemostasis (GIHP) guidelines provide the following recommendations:

• For low bleeding risk procedures: Discontinue apixaban at least 24 hours before the procedure 2
• For moderate to high bleeding risk procedures: Discontinue apixaban at least 48 hours before the procedure 2

For twice-daily dosing regimen of apixaban:

• Last intake should be on the morning of the day before the planned procedure 3
• Resume apixaban at least 6 hours after the procedure if there is no ongoing bleeding 3

Post-Extraction Management

If continuing apixaban during the extraction:

1. Apply local hemostatic measures (gelatin sponge, suturing as needed)
2. Consider tranexamic acid mouthwash (10 mL of 5% solution)
3. Monitor for bleeding every 30 minutes initially
4. Provide pressure pack with gauze for 1 hour post-extraction
5. Avoid strenuous physical activities for 48 hours after the procedure

Important Considerations

• Bridging anticoagulation is not recommended when temporarily discontinuing apixaban 3, 1
• Multiple studies have shown that dental extractions can be safely performed without discontinuation of antiplatelet therapy with appropriate local hemostasis 4, 5
• The risk of thromboembolic events from discontinuing anticoagulation may outweigh the risk of bleeding during minor dental procedures 1

Special Populations

• For patients with renal impairment (CrCl 30-50 mL/min), if discontinuation is chosen, consider extending the discontinuation period 1
• For patients over 80 years old, careful monitoring is required due to increased bleeding risk and potentially reduced renal function affecting drug clearance 1

Resumption of Apixaban

If apixaban was discontinued:

• Resume at least 6 hours after the procedure if adequate hemostasis has been established 3
• For twice daily regimen: Resume the evening of the same day 3
• For once daily regimen with morning intake: Resume the next morning 3
• For once daily regimen with evening intake: Resume the evening of the procedure day 3

The evidence strongly supports continuing apixaban for tooth extractions with appropriate local hemostatic measures rather than discontinuing it and risking thromboembolic events.