How Long to Hold Eliquis Prior to Dental Procedure
For a moderate-to-high bleeding risk dental procedure in a patient with normal renal function on standard-dose Eliquis, hold the medication for 48 hours (2 days) before the procedure—meaning skip 4 doses and give the last dose 2 days prior to surgery. 1
Risk Classification of Dental Procedures
Most routine dental work falls into the low-to-moderate bleeding risk category and requires only 24 hours of interruption. 2 However, certain dental procedures carry moderate-to-high bleeding risk:
- Low-risk procedures (24-hour hold): Simple extractions of 1-3 teeth, periodontal surgery, abscess incision, routine cleanings 2, 3
- Moderate-to-high risk procedures (48-hour hold): Extractions of more than 3 teeth, crown lengthening, open-flap surgery, surgical extractions, extensive periodontal surgery 3
Specific Timing for Eliquis Interruption
For patients on Eliquis 5 mg twice daily with normal renal function:
- Low-to-moderate bleeding risk dental procedures: Hold for 1 day (24 hours)—last dose on the morning of the day before the procedure 1, 2
- High bleeding risk dental procedures: Hold for 2 days (48 hours)—last dose 2 days before the procedure, skipping 4 doses total 1
The 2022 American College of Chest Physicians guidelines explicitly state that apixaban should be stopped 1 day before low-to-moderate-bleed-risk procedures and 2 days before high-bleed-risk procedures, regardless of whether the indication is atrial fibrillation or venous thromboembolism. 1
Why Renal Function Doesn't Change Apixaban Timing
Unlike dabigatran, apixaban timing remains constant regardless of kidney function (as long as creatinine clearance is >30 mL/min) because only 25% of the drug depends on renal clearance. 1, 2 The elimination half-life of apixaban is 7-8 hours, so 48 hours allows approximately 6 half-lives to elapse, resulting in >98% drug elimination. 1
Critical Management Points
Do NOT use bridging anticoagulation with heparin or low-molecular-weight heparin when stopping Eliquis for dental procedures—this significantly increases bleeding risk without reducing thrombotic risk. 2, 4
The FDA label for apixaban confirms that the drug "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" and "at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding." 5
Resuming Eliquis After the Dental Procedure
Restart Eliquis as early as 6 hours after the dental procedure once adequate hemostasis is established and bleeding has completely ceased. 2, 4 For higher-risk procedures with ongoing oozing, wait at least 24 hours before resumption. 1
Common Pitfalls to Avoid
- Never perform the procedure if there is any uncertainty about residual drug levels, particularly in elderly patients (>80 years) or those with unrecognized renal impairment 2
- Provide written instructions specifying the exact date/time of the last Eliquis dose and when to resume therapy 2
- Do not use INR to monitor Eliquis activity—it does not reliably reflect anticoagulant effect for direct oral anticoagulants 2
- Assess for drug interactions with P-glycoprotein inhibitors (e.g., dronedarone, amiodarone, verapamil) that can prolong Eliquis elimination 2