When to Stop Pradaxa (Dabigatran) Before Dental Extraction
For most patients with normal kidney function (CrCl >80 mL/min), stop Pradaxa 24 hours before dental extraction by skipping the morning dose on the day of the procedure. 1
Risk Stratification
Dental extractions (1-3 teeth) are classified as low bleeding risk procedures where adequate local hemostasis can be achieved. 1
Timing Based on Renal Function
Normal Renal Function (CrCl ≥80 mL/min)
- Stop 24 hours before the procedure 1
- For twice-daily dosing: Take last dose the morning of the day before extraction 1
- This allows one full half-life for drug clearance 1
Moderate Renal Impairment (CrCl 50-80 mL/min)
- Stop 48 hours (2 days) before the procedure 1
- Due to dabigatran's predominant renal elimination, longer interruption is required 1
Significant Renal Impairment (CrCl 30-50 mL/min)
- Stop 72-96 hours (3-4 days) before the procedure 1
- The French guidelines specifically recommend 4 days for this population 1
Severe Renal Impairment (CrCl <30 mL/min)
- Stop 96-120 hours (4-5 days) before the procedure 1
- The FDA label recommends 3-5 days for CrCl <50 mL/min 2
Critical Considerations
Age and Concomitant Medications
- Patients >80 years old: Consider adding an extra 24 hours to the interruption period 1
- P-glycoprotein inhibitors (verapamil, amiodarone, dronedarone): Add 24 hours to standard interruption time, especially if thromboembolic risk is not very high 1
What NOT to Do
- Do not use bridging anticoagulation with heparin or LMWH—this increases bleeding risk without reducing thrombotic events 1, 3
- Do not measure dabigatran levels routinely before low-risk procedures 1
Resumption After Extraction
- Resume at least 6 hours after the procedure if hemostasis is adequate 1, 3
- For twice-daily dosing: Resume the evening of the procedure day 1
- If ongoing bleeding or surgical contraindication exists, delay resumption and consider thromboprophylaxis 1
Local Hemostatic Measures
Dental extractions can be performed safely with adequate local measures including:
- Suturing
- Local hemostatic agents (tranexamic acid mouthwash, gelatin sponges)
- Pressure application 1
Important Caveats
Delayed bleeding risk: While skipping only the morning dose minimizes procedural bleeding, patients on dabigatran have increased risk of delayed bleeding (occurring days after the procedure) compared to non-anticoagulated patients. 4 Both patients and referring physicians must be informed of this risk and provided with clear instructions for managing post-procedural bleeding. 1
The patient should receive written instructions indicating the date/time of last dabigatran dose and emergency contact information. 1