Crovalimab Management for Wisdom Tooth Extraction
You do not need to stop crovalimab before wisdom tooth extraction. Dental procedures, including wisdom tooth extraction, are classified as low bleeding risk procedures that can be safely performed with local hemostatic measures while continuing complement inhibition therapy.
Rationale for Continuing Crovalimab
Crovalimab should be continued through dental procedures because the thrombotic risk of stopping complement inhibition in PNH far outweighs the manageable bleeding risk of tooth extraction. Patients with PNH face life-threatening thrombotic complications when complement inhibition is interrupted, while dental bleeding can be controlled with local measures 1.
Evidence from Anticoagulation Guidelines Applied to Complement Inhibitors
While no specific guidelines exist for crovalimab and dental procedures, the management principles from anticoagulation guidelines are directly applicable:
Dental extractions are consistently classified as low bleeding risk procedures across multiple guidelines, with bleeding being self-limiting and controllable with local hemostatic measures 1.
The American College of Chest Physicians recommends continuing anticoagulation with pro-hemostatic agents for dental procedures rather than interrupting therapy, even for patients on warfarin with INR in therapeutic range 1.
Multiple randomized trials showed no significant increase in bleeding when continuing anticoagulation for dental procedures (RR = 1.67; 95% CI: 0.97-2.89 for intra-procedural bleeding) 1.
Why Crovalimab Differs from Traditional Anticoagulants
Crovalimab is not an anticoagulant—it is a complement inhibitor that prevents intravascular hemolysis in PNH. The drug works by blocking C5 cleavage, thereby preventing terminal complement pathway activation 2, 3. Stopping crovalimab would:
Expose the patient to immediate risk of breakthrough hemolysis and potentially life-threatening thrombotic complications, which are the primary causes of morbidity and mortality in PNH 4, 5.
Require 4 weeks to re-establish steady-state complement inhibition after resumption, given crovalimab's monthly dosing schedule 2, 3.
Provide no meaningful reduction in bleeding risk, as crovalimab does not directly affect coagulation pathways like anticoagulants do 4, 5.
Practical Management Algorithm
Pre-Procedure Assessment
Verify that crovalimab dosing is up to date and the patient has maintained complete terminal complement inhibition 2.
Ensure meningococcal vaccination is current, as this is required for all patients on complement inhibitors 4, 5.
Assess local factors that increase bleeding risk: multiple tooth extractions (>3 teeth), poor gingival health, or need for extensive alveolar bone work 1.
Intra-Procedure Hemostatic Measures
Use local pro-hemostatic agents routinely for all PNH patients undergoing dental extraction:
Tranexamic acid mouthwash (5-10 mL of 5% solution) given immediately before the procedure and continued 2-3 times daily for 1-2 days post-procedure 1.
Additional local measures: extra sutures, gauze soaked in tranexamic acid, topical hemostatic agents, or fibrin glue as needed 1.
Minimize trauma: use atraumatic extraction techniques and achieve primary closure when possible 1.
Post-Procedure Monitoring
Continue crovalimab on the regular monthly schedule without interruption 4, 5.
Monitor for signs of breakthrough hemolysis: dark urine, fatigue, dyspnea, or abdominal pain, which would indicate inadequate complement inhibition 4, 5.
Manage minor oozing with local pressure and continued tranexamic acid rinses—this is expected and self-limiting 1.
Critical Pitfalls to Avoid
Never stop crovalimab for routine dental procedures. The risk-benefit calculation is clear:
Stopping crovalimab risks life-threatening PNH complications (thrombosis, hemolytic crisis) that carry significant mortality risk 4, 5.
Dental bleeding is manageable and rarely life-threatening, with studies showing <5% risk of clinically relevant bleeding when local hemostatic measures are used 1.
Do not confuse crovalimab management with direct oral anticoagulant (DOAC) management. While DOACs like apixaban require 24-48 hour interruption for dental work 6, crovalimab is not an anticoagulant and should not be stopped 4, 5, 2.
Avoid elective complex dental surgery during active PNH treatment. If extensive reconstructive dental work or multiple implants are planned, these should be deferred or performed in consultation with a hematologist, similar to recommendations for patients on bone-modifying agents 1.
Special Considerations for High-Risk Scenarios
For patients requiring extraction of >3 teeth or complex oral surgery:
Maintain crovalimab therapy but coordinate closely with the treating hematologist 4, 5.
Consider performing extractions in stages rather than all at once to minimize cumulative bleeding risk 1.
Use aggressive local hemostatic measures including suturing, packing, and extended tranexamic acid use 1.
For patients with recent switch from eculizumab to crovalimab: