Is it safe to hold the morning dose of Eliquis (apixaban) and restart at night for low bleeding risk dental procedures?

Management of Apixaban (Eliquis) for Low Bleeding Risk Dental Procedures

For low bleeding risk dental procedures, it is safe to hold the morning dose of apixaban (Eliquis) on the day of the procedure and restart it the same evening, provided there is no ongoing bleeding. 1, 2

Recommended Protocol for Apixaban Management with Dental Procedures

Classification of Dental Procedures by Bleeding Risk

• Low bleeding risk dental procedures include routine cleanings, simple extractions, restorative procedures, and non-surgical periodontal treatments 2
• These procedures can be safely performed with minimal interruption of apixaban therapy 2

Specific Management for Twice Daily Apixaban Regimen

• For low bleeding risk dental procedures, simply skip the morning dose on the day of the procedure 1
• Resume apixaban the same evening (at least 6 hours after the procedure) if adequate hemostasis is achieved 3, 1
• No bridging with heparin or LMWH is necessary for this brief interruption 3, 1

Timing Considerations

• The brief interruption (skipping only the morning dose) provides sufficient reduction in bleeding risk while minimizing thrombotic risk 1, 2
• According to the FDA label, apixaban should be discontinued at least 24 hours prior to procedures with low risk of bleeding 4
• However, for minor dental procedures specifically, the most recent guidelines suggest that even shorter interruptions are adequate 1, 2

Evidence Supporting This Approach

Safety Data

• Studies have shown that bleeding rates are low for dental procedures regardless of whether the DOAC was held or continued 2
• When bleeding does occur during dental procedures in patients on apixaban, it is typically mild and easily controlled with local hemostatic measures 2, 5
• The risk of thrombotic events during this brief interruption is extremely low 6, 7

Pharmacokinetic Considerations

• Apixaban has a relatively short half-life (approximately 12 hours), allowing for quick clearance and resumption 4, 8
• Even with a single missed dose, there is still some residual anticoagulant effect, providing continued thrombotic protection 8

Important Caveats and Considerations

• For higher bleeding risk dental procedures (multiple extractions, complex oral surgery), consider a longer interruption period of 48 hours 3
• Patients with renal impairment may require additional consideration as drug clearance is affected 4
• Local hemostatic measures (pressure, sutures, tranexamic acid mouthwash) should be readily available during the procedure 2
• If unexpected heavy bleeding occurs during the procedure, delay resumption of apixaban until adequate hemostasis is achieved 3
• Document the exact timing of the last dose taken and the planned resumption to ensure proper patient adherence 6

Resumption Protocol

• Confirm adequate hemostasis before resuming apixaban 3, 1
• Resume the regular twice-daily dosing schedule starting with the evening dose on the day of the procedure 3, 1
• If there are concerns about ongoing bleeding, postpone resumption and consider appropriate thromboprophylaxis if the patient is at high thrombotic risk 3