Higher risk of bleeding complications

For a patient who is taking a DOAC and requires dental treatment that is likely to cause bleeding, with a higher risk of bleeding complications (see Bleeding risks for dental procedures):

  • Advise the patient to miss (apixaban or dabigatran) or delay (rivaroxaban or edoxaban) their morning dose on the day of their dental treatment, and treat according to the general advice for managing bleeding risk.
    • If the patient usually takes their once-a-day rivaroxaban or edoxaban in the evening, there is no need to modify their medication schedule prior to the dental treatment

In addition:

  • Plan treatment for early in the day to allow for monitoring and management of bleeding complications, should they occur.
  • Consider carrying out the treatments in a staged manner, where possible, over separate visits.
  • Use local haemostatic measures to achieve haemostasis. Strongly consider suturing and packing, taking into account all relevant patient factors (see Haemostatic measures).
    • For rivaroxaban or edoxaban (taken once a day), the delayed morning dose may be taken 4 hours after haemostasis has been achieved. The next dose should be taken as usual the following morning. If the patient normally takes their rivaroxaban or edoxaban in the evening, they can take this at the usual time on the day of treatment as long as no earlier than 4 hours after haemostasis has been achieved
    • For apixaban or dabigatran (taken twice a day), having missed the morning dose, the patient should take their evening dose of DOAC at the usual time as long as no earlier than 4 hours after haemostasis has been achieved
    • Advise the patient to recontact the practice for advice if rebleeding occurs prior to, or after, restarting their DOAC
    • The patient should avoid missing subsequent doses of their DOAC, unless absolutely required in an emergency situation to control bleeding

Although many of the higher risk procedures are likely to be elective, there may be rare occasions when they are required urgently in an emergency situation.

In such cases, where the patient has already taken their morning dose of DOAC, it is advisable to delay the procedure until later in the day, where possible, to allow levels of anticoagulation to decrease.

There is limited evidence on the risk of bleeding complications for more invasive dental procedures in patients taking DOACs. The consensus of expert opinion is that patients should be advised to miss (apixaban or dabigatran) or delay (rivaroxaban or edoxaban) a dose of their DOAC prior to dental procedures that are likely to cause bleeding and which have a higher risk of bleeding complications (see Bleeding risks for dental procedures).

Because the risk of bleeding complications for these procedures is considered to be higher, the balance of effects is in favour of missing or delaying the pre-treatment DOAC dose.

Due to the short half-lives of the DOACs this will significantly reduce the level of anticoagulation at the time of dental treatment. The brief interruption and rapid onset of action of the DOACs when restarting reduces the period that the patient could be at sub-therapeutic anticoagulation levels and minimises the effect on thromboembolic risk.