How long should apixaban (a direct oral anticoagulant) be held before dental surgery?

Management of Apixaban for Dental Surgery

For minor dental procedures such as dental extractions, apixaban does not need to be discontinued as these are considered minimal-bleed-risk procedures with approximately 0% risk of major bleeding. 1

Classification of Dental Procedures by Bleeding Risk

• Dental procedures are generally classified as minimal-bleed-risk procedures, including dental extractions, restorations, prosthetics, endodontics, dental cleanings, and fillings 1
• These procedures can typically be performed without interruption of anticoagulation therapy 2, 3

Specific Recommendations for Apixaban Management

For Minor Dental Procedures:

• Continue apixaban without interruption for minor dental procedures (extractions, cleanings, fillings) 1
• No need for regular coagulation monitoring of patients on apixaban therapy 2
• Local hemostatic measures should be used to control bleeding (e.g., sutures, gelatin sponges, tranexamic acid mouthwash) 3

For More Complex Dental Surgeries:

If the dental procedure is considered to have a higher bleeding risk:

• For low-to-moderate-bleed-risk dental surgery: Discontinue apixaban 24 hours before the procedure (skip 2 doses) 4
• For high-bleed-risk dental surgery: Discontinue apixaban 48 hours before the procedure (skip 4 doses) 4
• Patients with renal impairment may require longer periods of interruption 1

Postoperative Management

• For minor dental procedures: Resume normal apixaban dosing schedule immediately after the procedure once hemostasis is achieved 1
• For more complex dental surgeries with higher bleeding risk: Resume apixaban 24 hours after surgery if adequate hemostasis has been established 4
• For high bleeding risk procedures: Consider resuming apixaban 48-72 hours postoperatively 1

Special Considerations

• Renal function should be assessed as it affects apixaban clearance (25% renal elimination) 1, 5
• No bridging with heparin is typically required due to the rapid onset and offset of action of apixaban 1
• Patients have an increased risk of delayed bleeding (occurring days after the procedure) even when following appropriate protocols 6
• For patients at high risk of thromboembolism undergoing high bleeding risk procedures, consider using a reduced dose when restarting (apixaban 2.5 mg twice daily) 1

Common Pitfalls and Caveats

• Avoid unnecessary interruption of apixaban for minor dental procedures as this increases thrombotic risk 2
• Be aware that delayed bleeding (occurring 1-7 days after the procedure) is more common in patients on apixaban compared to non-anticoagulated patients 6
• Provide clear post-procedure instructions to patients about managing potential delayed bleeding 3
• Consider the patient's thromboembolic risk when planning any interruption of anticoagulation 1
• Ensure adequate local hemostatic measures are available during the procedure 3

Following these guidelines will help minimize both bleeding complications and thrombotic events when managing patients on apixaban who require dental surgery.