From the Guidelines
Eliquis (apixaban) should be stopped 1-2 days before dental surgery, depending on the bleed risk associated with the surgery, and restarted 1-3 days after surgery.
Perioperative Management of Apixaban
- The decision to stop apixaban before dental surgery depends on the bleed risk associated with the procedure, with 1 day of interruption recommended for low-to-moderate-bleed-risk surgeries and 2 days for high-bleed-risk surgeries 1.
- For patients with normal or mildly impaired renal function, apixaban can be stopped 1-2 days before surgery, while those with moderately impaired renal function may require 2-3 days of interruption 1.
- After surgery, apixaban can be restarted 24 hours after a low-bleed-risk procedure and 48-72 hours after a high-bleed-risk procedure, with a potential reduced dose considered in patients at high risk for thromboembolism 1.
Key Considerations
- The half-life of apixaban is approximately 7-8 hours, which informs the timing of preoperative interruption and postoperative resumption 1.
- Renal function plays a crucial role in apixaban clearance, with impaired renal function requiring longer interruption periods 1.
- Bleed risk and thromboembolic risk must be carefully balanced when managing apixaban in the perioperative period 1.
From the FDA Drug Label
ELIQUIS should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding ELIQUIS should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled. ELIQUIS should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.
Eliquis (apixaban) should be stopped at least 48 hours before dental surgery with a moderate or high risk of bleeding, and at least 24 hours before dental surgery with a low risk of bleeding. It should be restarted after the procedure as soon as adequate hemostasis has been established 2.
From the Research
Perioperative Management of Eliquis (Apixaban)
- The management of Eliquis (apixaban) in patients undergoing dental surgery involves classifying the risk of procedure-related bleeding as minimal, low to moderate, or high risk 3.
- For patients undergoing minimal bleeding risk procedures, such as minor dental procedures, Eliquis may be continued or discontinued on the day of the procedure 3.
- For patients undergoing low to moderate bleeding risk procedures, Eliquis should typically be discontinued 1 day before the operation and restarted 1 day after 3.
- However, a study suggests that apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure 4.
- Another study reports that dental treatment may be safely delivered following continuation, partial interruption, or complete interruption of the Eliquis dose for dental treatment 5.
Specific Guidance for Dental Surgery
- A review of the literature proposes a peri-operative management protocol for patients taking direct oral anticoagulants, including Eliquis, undergoing oral surgery 6.
- The protocol suggests that interventions must be scheduled at the time of minimum blood concentration of the drug, and local measures favoring coagulation must be adopted 6.
- The decision to suspend the anticoagulant drug before oral surgery should only be made in consultation with the patient's general practitioner/cardiologist, who will weigh up the risk of bleeding from the proposed procedure with the risk of thrombosis/stroke in each individual patient 6.
Key Considerations
- The risk of bleeding and thromboembolism should be carefully assessed in patients taking Eliquis who are undergoing dental surgery 3, 7.
- The management of Eliquis in patients undergoing dental surgery should be individualized based on the patient's specific risk factors and the type of procedure being performed 3, 6.