Do you stop Eliquis (apixaban) before a tooth extraction?

Managing Apixaban During Tooth Extraction

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

Evidence-Based Approach to Dental Extractions on Apixaban

The American College of Chest Physicians guidelines and other major societies clearly classify minor dental procedures, including tooth extractions, as low bleeding risk procedures that do not require discontinuation of direct oral anticoagulants (DOACs) like apixaban 1. This approach balances the risk of thromboembolic events from stopping anticoagulation against the manageable bleeding risk during dental procedures.

Rationale for Continuing Apixaban

• Tooth extractions have minimal bleeding risk that can be controlled with local hemostatic measures
• Discontinuing anticoagulation increases thromboembolic risk unnecessarily
• Multiple studies show no significant difference in bleeding complications between patients who continue vs. discontinue oral anticoagulants during dental extractions 2

Management Protocol for Dental Extractions on Apixaban

1. Continue apixaban at regular dosing schedule

   • No need to skip or delay doses before the procedure
   • No bridging with heparin or LMWH is required 1

2. Apply local hemostatic measures during extraction:

   • Tranexamic acid mouthwash (10 mL of 5% solution) 1
   • Gelatine sponge placement in extraction socket
   • Suturing as needed
   • Gauze pressure

3. Post-extraction monitoring:

   • Monitor for bleeding every 30 minutes initially after the procedure 1
   • Observe the surgical site for the first 24 hours
   • Patient should avoid rinsing, spitting forcefully, or using straws for 24 hours

Special Considerations

• Timing considerations: If possible, schedule the extraction at least 6 hours after the last dose of apixaban to minimize bleeding risk 3

• Higher risk patients: For patients with additional bleeding risk factors (age ≥80 years, body weight ≤60 kg, renal impairment, or concomitant use of antiplatelet drugs), extra caution and more aggressive local hemostatic measures may be warranted 1

• Multiple extractions: The European Heart Rhythm Association guidelines suggest that even for multiple extractions (1-3 teeth), apixaban can be safely continued with appropriate local hemostasis 4

Important Caveats

• This recommendation applies to routine tooth extractions only. For extensive oral surgery procedures with high bleeding risk, the European Heart Rhythm Association recommends considering a 48-hour interruption of apixaban 4

• Avoid NSAIDs for post-extraction pain management as they may increase bleeding risk when combined with apixaban 4, 5

• If unexpected severe bleeding occurs, reversal with andexanet alfa or prothrombin complex concentrate may be necessary, though this is rarely required for dental procedures 1

The evidence strongly supports continuing apixaban during tooth extractions with appropriate local hemostatic measures rather than interrupting anticoagulation and increasing thromboembolic risk.