What pre-operative labs and medication adjustments are needed for a patient with a history of stroke, hypertension (HTN), and hyperlipidemia (HLD) taking Eliquis (apixaban), paroxetine, famotidine, atorvastatin, amlodipine, and olmesartan for tooth extractions?

Perioperative Management for Tooth Extractions in a Patient with Stroke History on Anticoagulation

For a 55-year-old female with history of stroke, hypertension, and hyperlipidemia on apixaban (Eliquis), the most appropriate perioperative management is to discontinue apixaban 2 days before the procedure if low bleeding risk or 3 days before if high bleeding risk, and obtain a complete blood count and renal function tests prior to the procedure.

Laboratory Testing Recommendations

• Complete blood count (CBC): Indicated due to the patient's anticoagulation with apixaban to assess baseline hemoglobin and platelet count 1
• Renal function tests (creatinine/BUN): Essential as apixaban dosing and perioperative management depends on renal function 1
• No routine electrocardiogram (ECG) is needed as dental extractions are considered low-risk procedures unless the patient has symptoms of active cardiovascular disease 1
• No routine chest radiography is indicated as this is a low-risk procedure with no pulmonary concerns noted 1
• No coagulation studies (PT/INR) are needed as they do not reliably measure the anticoagulant effect of direct oral anticoagulants like apixaban 1

Medication Management

Apixaban (Eliquis)

• Discontinue apixaban based on bleeding risk assessment of the dental procedure:
  • For low bleeding risk dental extractions: Last dose 2 days before surgery (skip 2 doses) 1
  • For high bleeding risk extensive extractions: Last dose 3 days before surgery (skip 4 doses) 1
• Resume apixaban 24 hours after procedure for low bleeding risk or 48-72 hours after procedure for high bleeding risk 1
• Consider prophylactic low molecular weight heparin 6-8 hours after surgery if there are concerns about bleeding, and delay resuming apixaban for 48 hours 1

Antihypertensive Medications

• Continue amlodipine and olmesartan through the perioperative period, including the morning of surgery 1
• Abrupt withdrawal of antihypertensive medications can lead to rebound hypertension and increased risk of cardiovascular events 1
• Maintaining blood pressure control is important to reduce perioperative ischemic episodes 1

Other Medications

• Continue atorvastatin through the perioperative period 2, 3
• Continue paroxetine and famotidine as these medications do not significantly impact surgical bleeding risk 1

Special Considerations

• Stroke history increases risk: The patient's history of stroke in 2022 places her at higher risk for perioperative cardiovascular complications 1
• Bridging anticoagulation: Not routinely recommended for patients on apixaban undergoing dental procedures unless the patient has had a stroke within the last 3 months 1
• Local hemostatic measures: Recommend coordination with the dentist for local hemostatic measures such as absorbable gelatin sponges, tranexamic acid mouthwash, or sutures 1
• Blood pressure monitoring: Ensure adequate blood pressure control before the procedure as uncontrolled hypertension may increase bleeding risk 1

Common Pitfalls to Avoid

• Don't discontinue antihypertensive medications: Abrupt cessation of antihypertensives can lead to rebound hypertension 1
• Don't routinely order unnecessary preoperative tests: Tests should be guided by the patient's clinical history and physical examination findings, not by protocol 1, 4
• Don't restart apixaban too early: This could increase bleeding risk; timing should be based on the specific bleeding risk of the procedure 1
• Don't assume PT/INR accurately reflects apixaban activity: Standard coagulation tests don't reliably measure direct oral anticoagulant effects 1