When should Eliquis (apixaban) be discontinued prior to a dental procedure?

From the Guidelines

For a tooth procedure, it is recommended to stop taking Eliquis (apixaban) at least 48 hours before the dental work for high bleeding risk procedures, and potentially not at all for minimal bleeding risk procedures, as suggested by the most recent guidelines 1. When considering the management of Eliquis (apixaban) for patients undergoing tooth procedures, several factors come into play, including the type of procedure, the patient's renal function, and their individual bleeding risk.

• The half-life of apixaban is approximately 12 hours, which means that most of the medication will be cleared from the system within 24-48 hours.
• According to the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery, for patients taking apixaban, the medication should be withheld for a certain period before procedures based on the bleeding risk 1.
• For high bleeding risk procedures, withholding apixaban 48 hours before the procedure may be necessary, while for low or minimal bleeding risk procedures, the guidelines suggest that apixaban may not need to be withheld at all, or only withheld for a shorter period.
• It's crucial to consult with both the dentist and the doctor who prescribed Eliquis to determine the best approach based on individual patient factors and the specific procedure being performed.
• After the procedure, apixaban can usually be resumed once adequate hemostasis is achieved, typically within 24 hours, but this should be done under the guidance of a healthcare provider.
• The decision to stop or continue apixaban should always prioritize minimizing the risk of bleeding while also considering the risk of thromboembolic events, especially in patients with conditions like atrial fibrillation.

From the FDA Drug Label

Apixaban tablets 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 [see Warnings and Precautions (5. 2)] . Apixaban tablets 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.

Stopping Eliquis (apixaban) prior to a tooth procedure:

• For procedures with a moderate or high risk of bleeding, stop apixaban at least 48 hours before the procedure.
• For procedures with a low risk of bleeding, stop apixaban at least 24 hours before the procedure. 2

From the Research

Stopping Eliquis Prior to a Tooth Procedure

• There is no direct evidence on when to stop Eliquis (apixaban) prior to a tooth procedure, but studies on similar anticoagulants provide some guidance 3, 4, 5, 6, 7.
• The American College of Cardiology and other organizations suggest that for most patients, anticoagulation therapy, including Eliquis, should not be discontinued for dental procedures, as the risk of bleeding is low and the risk of thromboembolic events is higher if anticoagulation is interrupted 3, 7.
• A study on rivaroxaban, another new oral anticoagulant, found that dental implant surgery could be performed safely without interrupting or modifying anticoagulant medication, with local hemostatic measures applied as needed 6.
• The management of patients on apixaban requires careful assessment and consideration of the patient's individual risk factors, as well as the type and complexity of the dental procedure 4, 5.
• Local measures, such as the application of antifibrinolytic agents, can be effective in controlling bleeding in patients on anticoagulation therapy, including Eliquis 6, 7.

Key Considerations

• The decision to stop or continue Eliquis prior to a tooth procedure should be made on a case-by-case basis, taking into account the patient's individual risk factors and the type and complexity of the procedure 4, 5.
• Close communication and collaboration between the patient's healthcare provider, dentist, and other healthcare professionals is essential to ensure safe and effective management of anticoagulation therapy during dental procedures 3, 7.