Two extractions in a patient on apixaban with a history of post-operative bleeding
A 66-year-old woman requests removal of 16 and 37, both grossly carious and unrestorable. Her medical history includes atrial fibrillation on apixaban 5 mg twice daily and hypertension on amlodipine; her last apixaban dose was ten hours ago and her eGFR from last month is 78 mL/min/1.73 m². She also takes ibuprofen 400 mg occasionally for knee pain and asks whether she can take some after the extractions. Three years ago, while taking warfarin, she bled for two days after an extraction and needed a hospital visit, which she recalls vividly. Blood pressure today is 158/92 mmHg, with generalised gingival inflammation and visible plaque. She has no history of stroke or bleeding disorder. A dentist in the practice suggests stopping apixaban for three days before surgery, and the patient is anxious to know whether that is safe.
1. Critique the suggestion to stop apixaban and describe how you would plan the procedure with her physician.
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Reject the suggestion. Apixaban is a direct factor Xa inhibitor with a half-life of about 12 hours. Interrupting it for three days creates a thrombotic risk - stroke in atrial fibrillation - that is far greater than the bleeding risk of two routine extractions. Current guidance is that single simple extractions can be performed without interrupting direct oral anticoagulants, using local haemostatic measures; only for higher-risk procedures is a missed or delayed dose considered, and then only after discussion with the prescriber.
Facts to gather: renal function (her eGFR is acceptable), concomitant antiplatelets or NSAIDs, her bleeding history, whether the extractions will be simple or surgical, and her own preference after explanation.
The prescriber decides, not the dentist. Write to her physician or cardiologist with the planned procedure and date, state that you intend to proceed without interruption, and ask whether the timing of the dose should be adjusted around the appointment. That is a shared decision, documented in the notes.
Do not stop an anticoagulant on a hunch: a stroke precipitated by a dental appointment is a catastrophe that no amount of local packing justifies. Address her anxiety directly - her previous bleeding occurred under a different drug and without a pre-emptive plan.
2. Give your operative plan: local anaesthesia, technique, haemostatic measures and analgesia.
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Before the appointment: her BP of 158/92 is not a reason to cancel, but uncontrolled hypertension promotes bleeding; consider deferring elective extractions until it has been reviewed, especially with her history. Optimise local factors first - scaling to reduce gingival inflammation, and chlorhexidine mouthwash.
Local anaesthesia: 2% lidocaine with 1:100,000 adrenaline is acceptable with an aspirating technique and dose limitation; monitor her during the appointment. Avoid unnecessary adrenaline load in an uncontrolled hypertensive.
Technique: atraumatic extraction with periotome and careful forceps use, curettage of granulation tissue from the sockets, and primary closure with sutures.
Local haemostasis: oxidised cellulose or a collagen plug in the socket, a figure-of-eight suture, and gauze pressure for 10–20 minutes. Add tranexamic acid 4.8–5% mouthwash, 10 mL four times daily for 2–5 days, starting the same day.
Analgesia: paracetamol, not ibuprofen. An NSAID plus apixaban substantially increases bleeding risk, so answer her question with a clear 'no' and explain why.
Instructions: no rinsing, spitting, smoking, hot drinks or strenuous exercise for 24 hours; apply gauze pressure if bleeding recurs; contact the clinic or emergency department if bleeding persists beyond 20 minutes of firm pressure.
3. She returns the next evening with bleeding. How would you assess and manage her, and when would you escalate?
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Assess first, treat second. Check pulse, blood pressure, pallor and mental state, and decide whether this is oozing or active arterial bleeding. Sit her upright, take a focused history (missed or extra doses, NSAIDs or aspirin, rinsing, smoking, alcohol), and inspect after removing the clot.
Local control: infiltrate local anaesthetic with adrenaline, identify the source (socket margin, torn papilla, granulation tissue), curette the socket, place a haemostatic agent, suture, and apply sustained pressure for 20 minutes. Most post-extraction bleeding is local and stops with this.
Look for avoidable causes: elevated blood pressure, NSAID use, a retained root or granulation tissue, and instructions not followed at home.
Escalate if bleeding persists after two attempts at local control, if it is brisk or arterial, if she is hypotensive or syncopal, or if a coagulopathy is suspected - refer to the oral and maxillofacial unit or emergency department with the anticoagulant details and timings.
Reassure her: her previous experience is precisely why the plan is different this time - the anticoagulant was not stopped, local measures were used pre-emptively, and she has a written plan and a contact number. Record the review, the measures taken and the advice given.