Apixaban Suspension for Dental Procedures
For most dental procedures, stop apixaban 1 day before (skip 2 doses) and resume 24 hours after the procedure once hemostasis is established; however, patients with impaired renal function (CrCl <30 mL/min) require 3 days of preoperative discontinuation even for routine dental work. 1
Bleeding Risk Classification for Dental Procedures
Most dental procedures fall into the minimal to low-moderate bleeding risk category, which includes:
- Simple extractions
- Minor periodontal procedures
- Dental cleanings with minimal tissue manipulation 2
Complex dental procedures (multiple extractions, extensive periodontal surgery) may be classified as low-moderate bleeding risk, requiring the same management approach 2, 1.
Preoperative Management Based on Renal Function
Normal or Mild Renal Impairment (CrCl ≥50 mL/min)
- Stop apixaban 1 day before the procedure (skip 2 doses for twice-daily dosing) 1
- This corresponds to 2-3 half-lives, leaving 3-6% residual anticoagulant effect 1
- The FDA label recommends discontinuation at least 24 hours prior for procedures with low bleeding risk 3
Moderate Renal Impairment (CrCl 30-49 mL/min)
- Stop apixaban 3 days before the procedure 1
- Extended interruption is essential as apixaban accumulates with declining renal function 1
Severe Renal Impairment (CrCl <30 mL/min)
- Stop apixaban 3 days before the procedure 1
- Consider measuring apixaban levels if available, as these patients can experience catastrophic bleeding including rare sites 1
- Apixaban may still be safer than warfarin in this population based on recent data 4, 5
Postoperative Resumption Strategy
Resume apixaban 24 hours after the dental procedure at the usual dose, ensuring:
- At least 6 hours have elapsed since the procedure 1
- Adequate hemostasis is clearly established 2, 1
- No active oozing or bleeding from the surgical site 1
The rapid onset of action of apixaban (peak effect in 3-4 hours) makes premature resumption particularly dangerous if hemostasis is incomplete 1.
Critical Management Principles
No Bridging Anticoagulation Required
- Do not use heparin or low-molecular-weight heparin bridging during the interruption period 1, 3
- Bridging increases major bleeding risk without reducing stroke or systemic embolism 1
- The short interruption period and rapid offset/onset of apixaban make bridging unnecessary 1
Thrombotic Risk Considerations
For patients at very high thrombotic risk (recent stroke, mechanical heart valve, recent VTE):
- The brief 1-3 day interruption for dental procedures poses minimal thrombotic risk 2
- Delaying elective dental procedures may be considered in patients with thrombosis within the past 1-3 months 2
- Even in high-risk patients, bridging is not recommended for DOAC interruption 1
Common Pitfalls to Avoid
Premature resumption after complex procedures: The rapid onset of apixaban can precipitate major bleeding if hemostasis is incomplete—wait the full 24 hours and confirm hemostasis 1.
Inadequate interruption in renal impairment: Standard coagulation tests (INR, aPTT) do not reliably detect apixaban effect; rely on the extended interruption periods for patients with CrCl <50 mL/min 1.
Unnecessary bridging: This outdated practice significantly increases bleeding risk without benefit for DOACs 1, 3.
Ignoring drug interactions: Patients taking combined P-gp and strong CYP3A4 inhibitors (ketoconazole, ritonavir) may have elevated apixaban levels requiring extended interruption 3.
Special Considerations
Monitoring
- Anti-Xa activity correlates well with apixaban exposure if measurement is needed 1
- Standard coagulation tests are not useful for monitoring apixaban effect 1