Do I need to hold Eliquis (apixaban) before a dental procedure?

Management of Eliquis (Apixaban) for Dental Procedures

For most dental procedures, you do not need to hold Eliquis (apixaban), as the bleeding risk is minimal and can be managed with local hemostatic measures. 1, 2, 3

Risk Stratification of Dental Procedures

The decision to hold apixaban depends on the bleeding risk of the specific dental procedure:

Low Bleeding Risk Procedures (No Interruption Needed)

• Continue apixaban without interruption for procedures such as simple dental cleaning, fillings, simple extractions (1-3 teeth), periodontal probing, and supragingival scaling 2, 3
• Use local hemostatic measures (tranexamic acid mouthwash, gelatin sponges, sutures) to control any minor bleeding 2, 3
• These procedures can be safely performed while maintaining therapeutic anticoagulation 4

Higher Bleeding Risk Procedures (Consider Brief Interruption)

• For more invasive procedures such as multiple extractions, flap surgeries, or extensive periodontal surgery, hold apixaban for 24 hours before the procedure 5
• The FDA label specifically states that apixaban should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding 5
• For procedures with moderate to high bleeding risk, hold apixaban for 48 hours before the procedure 1, 5

Specific Timing Recommendations

Preoperative Management

• Last dose timing for twice-daily regimen: Take the morning dose on the day before the procedure (24-hour hold) for low-risk procedures 1
• For higher-risk dental procedures: Hold for 48 hours, meaning skip 4 consecutive doses 1
• The French Working Group on Perioperative Hemostasis recommends a minimum 3-day interruption for high hemorrhagic risk procedures when creatinine clearance is >30 mL/min 6

Important Considerations

• No bridging with heparin is needed for dental procedures, as this increases bleeding risk without reducing thrombotic events 6, 1, 2
• Check renal function if not recently assessed, as this affects drug clearance 6
• Consider P-glycoprotein inhibitors and CYP3A4 inhibitors that may prolong apixaban levels 6

Postoperative Resumption

• Resume apixaban at least 6 hours after the procedure once adequate hemostasis is achieved 1, 5
• Return to the regular twice-daily dosing schedule, starting with the evening dose on the day of the procedure 1
• If there is ongoing bleeding or concerns about hemostasis, delay resumption until bleeding is controlled 1, 5
• The FDA label emphasizes that apixaban should be restarted "as soon as adequate hemostasis has been established" 5

Critical Pitfalls to Avoid

• Never bridge with heparin for dental procedures—this significantly increases bleeding risk without reducing thrombotic complications 6, 1, 2
• Do not stop apixaban unnecessarily for simple procedures, as the thrombotic risk from interruption outweighs the minimal bleeding risk 2, 3
• Ensure the patient informs you they are taking apixaban before any procedure, as the FDA label specifically instructs patients to tell dentists about their anticoagulation 5
• Avoid performing neuraxial anesthesia if apixaban has not been held for sufficient time (this is more relevant for medical procedures but worth noting) 5

Evidence Quality Note

Multiple systematic reviews and clinical trials demonstrate that continuing oral anticoagulation during most dental procedures does not increase clinically significant bleeding 2, 4. The short follow-up periods in studies mean thromboembolic events from interruption may be underreported, but the well-established risk of stopping anticoagulation supports continuation when possible 2.