Management of Apixaban for Dental Surgery
For most dental procedures, apixaban does not need to be interrupted, and local hemostatic measures are sufficient to manage bleeding risk. 1, 2
Risk Stratification of Dental Procedures
Low Bleeding Risk Procedures (No Interruption Required)
- Simple dental extractions (1-3 teeth), dental cleaning, fillings, and periodontal procedures can be performed without stopping apixaban. 3, 2
- Local hemostatic measures such as tranexamic acid mouthwash, sutures, and hemostatic packing materials should be readily available. 2
- Resume normal oral hygiene and diet immediately after adequate local hemostasis is achieved. 2
Higher Bleeding Risk Procedures (Consider Interruption)
- For complex extractions, multiple extractions (>3 teeth), or invasive oral surgery, interrupt apixaban for 24-48 hours before the procedure. 1, 4
- The FDA label recommends discontinuing apixaban at least 24 hours prior to procedures with low bleeding risk and at least 48 hours for moderate-to-high bleeding risk. 4
- For twice-daily apixaban regimens, the last dose should be taken on the morning of the day before surgery. 5, 1
Timing of Interruption Based on Renal Function
Apixaban has minimal renal clearance (25%), so standard interruption times apply even with mild-to-moderate renal impairment. 6
- For procedures requiring interruption, stop apixaban 48 hours (2 days) before surgery regardless of renal function. 5
- This corresponds to approximately 4-5 half-lives, resulting in minimal residual anticoagulant effect. 6
Bridging Anticoagulation
Do not use bridging anticoagulation with heparin or low-molecular-weight heparin for dental procedures. 5, 1
- Recent evidence demonstrates increased hemorrhagic risk during perioperative bridging without reduction in thromboembolic risk. 5
- Bridging is only considered for very high thrombotic risk patients, which is exceedingly rare in the dental surgery context. 5
Resumption of Apixaban After Dental Surgery
Resume apixaban at least 6 hours after the procedure once adequate hemostasis is confirmed. 5, 1, 6
- For low bleeding risk procedures, restart the regular twice-daily dosing schedule starting with the evening dose on the day of the procedure. 1
- If unexpected heavy bleeding occurs or hemostasis is uncertain, delay resumption for 24-48 hours and use local hemostatic measures. 1, 4
- Do not double the dose to compensate for missed doses. 4
Laboratory Monitoring
Routine coagulation monitoring or measurement of apixaban levels is not necessary before dental procedures. 5, 7, 8
- Standard coagulation tests (PT/INR, aPTT) do not reliably reflect apixaban anticoagulant effect. 5
- Specific anti-Xa assays are available but not routinely indicated for dental procedures. 5
Critical Pitfalls to Avoid
- Do not perform neuraxial anesthesia or deep nerve blocks if apixaban has not been adequately discontinued. 5
- Avoid unnecessary interruption for simple procedures, as this increases thromboembolic risk without benefit. 3, 2
- Confirm the patient's renal function before planning interruption, though apixaban is less affected than dabigatran. 5, 6
- Check for concomitant P-glycoprotein or strong CYP3A4 inhibitors (ketoconazole, ritonavir), which increase apixaban levels and may require dose adjustment. 4
- Ensure adequate local hemostatic measures are in place before resuming apixaban, particularly for higher-risk extractions. 1, 2
Special Considerations
- For patients on apixaban 2.5 mg twice daily (reduced dose), the same interruption and resumption guidelines apply. 5
- Coordinate with the prescribing physician for patients with recent thromboembolism (within 3 months) or mechanical heart valves, as these require individualized assessment. 5
- Consider postponing elective dental procedures if the patient is in the early treatment phase of venous thromboembolism requiring higher apixaban doses (10 mg twice daily). 5