What is the recommended duration to stop Dabigatran (Pradaxa) before a tooth extraction?

Dabigatran Management Before Tooth Extraction

For routine tooth extractions in patients with normal renal function (CrCl ≥50 mL/min), stop dabigatran 1 day (24 hours) before the procedure, which means skipping the dose on the morning of extraction. 1

Risk Stratification

Tooth extractions are classified as minimal-to-low bleeding risk procedures where adequate local hemostasis can be achieved. 1

• Minor dental procedures including extractions, restorations, prosthetics, and endodontics fall into the low-to-moderate bleeding risk category 1
• These procedures allow for some residual anticoagulant effect (2-3 drug half-lives) at the time of surgery 1

Specific Interruption Protocol Based on Renal Function

Normal Renal Function (CrCl ≥50 mL/min)

• Stop dabigatran 1 day before extraction (skip morning dose on day of procedure) 1
• This provides 24 hours of interruption, allowing 2-3 half-lives to elapse 1
• The FDA label supports 1-2 days interruption for patients with CrCl ≥50 mL/min 2

Impaired Renal Function (CrCl <50 mL/min)

• Stop dabigatran 2 days before extraction 1
• Dabigatran is 80% renally cleared, requiring longer interruption in renal impairment 1

Severe Renal Impairment (CrCl <30 mL/min)

• Stop dabigatran 3-5 days before extraction 2
• The FDA recommends 3-5 days for invasive procedures in this population 2

Critical Management Points

No Bridging Required

• Do not bridge with heparin or LMWH 1
• The rapid offset of dabigatran eliminates the need for bridging anticoagulation 1
• Bridging increases bleeding risk without reducing thrombotic events 1
• One case report documented severe bleeding when bridging was inappropriately used for tooth extraction 3

Resumption After Extraction

• Resume dabigatran at least 24 hours after the procedure once adequate hemostasis is achieved 1
• The FDA recommends restarting "as soon as medically appropriate" 2
• Dabigatran reaches peak effect 1-3 hours after intake, requiring cautious timing 1

Alternative Approach for Simple Extractions

Some evidence supports an even more conservative approach:

• Skip only the morning dose on the day of extraction (approximately 12 hours interruption) 4, 5
• One prospective study of 26 patients showed this approach avoided excess procedural bleeding 5
• The European Heart Rhythm Association suggests dental extractions can be performed safely without suspending NOAC treatment with adequate local measures 1

However, the 24-hour interruption (1 day) remains the guideline-recommended standard per the American College of Chest Physicians 2022 guidelines, which represent the highest quality evidence. 1

Important Caveats

Delayed Bleeding Risk

• Patients on dabigatran have increased risk of delayed bleeding (occurring days after extraction) even with appropriate interruption 5
• Provide clear post-operative instructions and ensure accessibility for bleeding management 1

Drug Interactions

• Avoid concomitant P-gp inhibitors (dronedarone, amiodarone, verapamil) in patients with CrCl <50 mL/min 2
• Consider adding an extra 24 hours of interruption if patient is on these medications 1

Local Hemostatic Measures

• Use tranexamic acid mouthwash, absorbable hemostatic agents, and suturing 1
• Avoid NSAIDs post-operatively 1

Emergency Reversal

• Idarucizumab is available for emergency reversal if uncontrolled bleeding occurs 2