Should a patient discontinue Eliquis (apixaban) 5mg twice daily for a dental extraction?

Management of Eliquis (Apixaban) for Dental Extraction

For a patient on Eliquis 5mg twice daily undergoing a dental extraction, discontinue the medication by taking the last dose on the morning of the day before the procedure, then resume the evening of the procedure day once adequate hemostasis is achieved. 1, 2

Procedure Risk Classification

• Dental extractions are generally classified as low bleeding risk procedures where bleeding would be easily controlled and non-critical in location 3
• Simple dental procedures like fillings require only omitting the morning dose on the day of the procedure, but extractions typically warrant slightly longer interruption 2

Discontinuation Protocol for Twice-Daily Apixaban

For the standard 5mg twice-daily regimen:

• Take the last dose on the morning of the day before the dental extraction (approximately 24-36 hours before the procedure) 4, 1
• This timing applies to patients with normal renal function (creatinine clearance >30 mL/min) 4
• The FDA label specifies discontinuing at least 24 hours prior to elective procedures with low risk of bleeding 3

For higher-risk dental extractions or patient-specific concerns:

• Consider extending the interruption period to 48 hours if there are concerns about bleeding risk 1
• Patients with impaired renal function may require longer discontinuation periods (up to 72 hours for creatinine clearance <50 mL/min) 2
• Check for P-glycoprotein or CYP3A4 inhibitors (e.g., ketoconazole, ritonavir) which may require an additional 24-hour extension 2

Critical Points About Bridging

Do NOT use heparin bridging for dental extractions - this significantly increases bleeding risk without reducing thrombotic events 4, 1

• Bridging anticoagulation is not recommended for low bleeding risk procedures 4
• Recent evidence demonstrates increased bleeding with bridging without benefit regarding thromboembolic risk 4

Resumption Protocol

Resume apixaban the evening of the procedure day (at least 6 hours post-procedure) once adequate hemostasis is confirmed 4, 1

• For twice-daily regimens, restart with the evening dose on the same day as the procedure 4
• Return to the regular twice-daily dosing schedule immediately 1

Delay resumption if:

• There is ongoing bleeding or surgical contraindication 4
• Adequate hemostasis has not been achieved 1, 2
• In these cases, consider appropriate thromboprophylaxis if the patient is at high thrombotic risk 1

Common Pitfalls to Avoid

• Do not assume 48 hours is necessary for routine dental extractions - this is excessive for most simple extractions with normal renal function 1, 2
• Do not forget to assess renal function - impaired clearance necessitates longer hold times 2
• Do not bridge with heparin - this increases bleeding risk without benefit 4, 1
• Do not resume too early - ensure at least 6 hours have passed and hemostasis is adequate 4, 1
• Do not measure apixaban concentration before the procedure - this is unnecessary for routine management 4

Patient-Specific Modifications

Assess these factors before finalizing the plan:

• Renal function (creatinine clearance) - longer hold times needed if <50 mL/min 4, 2
• Concomitant medications that affect apixaban metabolism (P-gp and CYP3A4 inhibitors) 2, 3
• Complexity of the dental extraction (simple vs. surgical extraction) 1
• Patient age >80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL may affect drug clearance 5