How long before a dental extraction should a patient stop taking Eliquis (apixaban) and Alendronate (bisphosphonate)?

Management of Eliquis and Alendronate Before Dental Extraction

For dental extractions, Eliquis (apixaban) should be discontinued 24 hours before low bleeding risk procedures and 48 hours before high bleeding risk procedures, while alendronate can be continued without interruption.

Apixaban (Eliquis) Management

Timing of Discontinuation

• For low bleeding risk dental extractions:

  • Discontinue apixaban 24 hours before the procedure (skip the dose on the morning of the procedure) 1, 2
  • This means omitting only the morning dose on the day of the procedure if on a twice-daily regimen 1

• For high bleeding risk dental extractions:

  • Discontinue apixaban 48 hours before the procedure 1, 2
  • This means stopping apixaban 2 days before the procedure 3

Risk Stratification for Dental Procedures

• Low bleeding risk dental procedures:

  • Simple extractions (1-3 teeth)
  • Procedures where bleeding can be easily controlled with local measures

• High bleeding risk dental procedures:

  • Multiple extractions
  • Complex surgical extractions
  • Procedures involving significant tissue trauma
  • Procedures in patients with additional risk factors (advanced age ≥75 years, history of bleeding, concurrent antiplatelet agents) 3

Resuming Apixaban

• Resume apixaban as soon as adequate hemostasis has been established 2
• For low bleeding risk procedures: resume 24 hours after the procedure 3
• For high bleeding risk procedures: resume 48-72 hours after the procedure 3
• No bridging anticoagulation is generally required during this interruption 2

Alendronate Management

Timing of Discontinuation

• No discontinuation of alendronate is required before dental extractions
• The evidence does not support the need to discontinue bisphosphonates before dental procedures 4
• Long-term studies show successful dental implant treatment outcomes in patients on alendronate therapy 4

Special Considerations for Alendronate

• Alendronate is primarily used for prevention of osteoporotic fractures 5
• Unlike anticoagulants, bisphosphonates do not directly affect the coagulation cascade
• The primary concern with bisphosphonates is the rare risk of medication-related osteonecrosis of the jaw (MRONJ), not increased bleeding risk

Additional Measures to Reduce Bleeding Risk

• Use local hemostatic measures after extraction:

  • Gelatin sponge
  • Suturing when necessary 6
  • Consider tranexamic acid mouthwash to reduce post-extraction bleeding 7

• Use minimally invasive surgical techniques 4

• Maintain good oral hygiene before and after the procedure

• Schedule the extraction early in the day and week to allow for management of any delayed bleeding complications

Monitoring and Follow-up

• Monitor for bleeding during the first 24-72 hours after extraction
• Be aware that delayed bleeding (after 24 hours) may occur more frequently in anticoagulated patients 8
• Provide clear instructions to patients about when to seek help if bleeding occurs
• Ensure patients understand the importance of resuming apixaban as directed to prevent thromboembolic events

Special Considerations

• For patients with renal impairment (CrCl 30-50 mL/min), consider extending the discontinuation period for apixaban to 72 hours before high bleeding risk procedures 3
• For patients at very high thrombotic risk (recent history of pulmonary embolism or deep venous thrombosis), consult with the patient's cardiologist or hematologist regarding the management strategy 3

Remember that the risk of thromboembolic events from prolonged interruption of anticoagulation may outweigh the risk of bleeding during dental procedures, so minimize the time off anticoagulation whenever possible.