For a patient who is taking a DOAC and requires a dental procedure with a low risk of bleeding complications, treat without interrupting their anticoagulant medication (see Low risk of bleeding complications section).
(Conditional recommendation; very low certainty evidence) [amended 2022]
For a patient who is taking a DOAC and requires a dental procedure with a higher risk of bleeding complications, advise them to miss (apixaban, dabigatran) or delay (rivaroxaban, edoxaban) their morning dose on the day of their dental treatment (see Higher risk of bleeding complications section).
(Conditional recommendation; very low certainty evidence) [amended 2022]
Refer to Section 5 of the full guidance.
These key recommendations were amended, following review in 2022, to apply for patients taking edoxaban, in addition to patients taking apixaban, dabigatran or rivaroxaban.
There is a growing body of direct evidence and clinical experience relating to invasive dental treatment for patients taking a DOAC. Recent evidence suggests that while there may be a higher risk of post-operative bleeding complications for patients taking DOACs compared with no anticoagulant, there might not be a significant difference when comparing continuing versus interrupting DOAC therapy for a range of dental procedures. There is limited evidence on the more invasive procedures.
The recommendations are based on the available evidence, the balance of likely effects of each option for each dental procedure, the known characteristics of the drugs, such as their short half-lives and rapid onset of action and consensus of expert opinion.
They are conditional recommendations because of the limited evidence and the fine balance between the potential risks and benefits of the treatment options.
Patients waiting for cardioversion can require at least 3 weeks of uninterrupted anticoagulation prior to the procedure. While these patients will rarely be encountered, it is important to note that their anticoagulation therapy should not be modified.
The estimated risk to the patient of a thromboembolic event resulting from brief DOAC interruption is judged to be extremely small, while the risk of a bleeding complication if the DOAC is continued is likely to be small but also depends on the procedure involved and the individual patient.
The potential risks from either continuing or interrupting a patient’s DOAC medication are both uncertain, and the anticoagulant management options and risks should be discussed with the patient.
For a patient who is taking a DOAC and requires dental treatment that is likely to cause bleeding, with either a low or higher risk of bleeding complications (see Bleeding risks for dental procedures):
Since the advice on interruption of medication is for a patient to miss at most a single dose of DOAC, or to delay for several hours, it is not usually necessary to consult with the patient’s medical practitioner first. However, if the dental practitioner or patient has any concerns then they should discuss these with the patient’s prescribing clinician, specialist or general medical practitioner.
Monitoring
Quantitative laboratory tests for assessing coagulation levels in patients taking DOACs are not widely available and the INR test used for warfarin (see Warfarin or another Vitamin K antagonist) is not suitable for these drugs. However, since the DOACs generally provide more predictable anticoagulation, monitoring is considered less important than for warfarin and is not carried out routinely.
Pharmacokinetics
Compared to warfarin, the DOACs exhibit a rapid onset of action (1-4 hours) and have relatively short half-lives (5-13 hours for rivaroxaban, ~12 hours for apixaban, ~10-14 hours for edoxaban and ~13-18 hours for dabigatran, depending on renal function and age).
Because of these pharmacokinetic properties, it is possible to modify an individual’s anticoagulation status quite rapidly, minimising the period where the anticoagulation activity is therapeutically sub-optimal.
In the event of severe bleeding, the short half-lives of these drugs allow for the relatively rapid reduction of their anticoagulant effects. In addition, specific reversal agents for dabigatran, apixaban and rivaroxaban are available for use in hospital settings for life-threatening bleeding.
Dose schedule
Apixaban (Eliquis) and dabigatran (Pradaxa) are taken twice a day, while rivaroxaban (Xarelto) and edoxaban (Lixiana) are most commonly taken once a day, either in the morning or at night. For each of the drugs, a lower dose is indicated for certain patients including those with various levels of renal impairment and in some cases older people.
Patients with acute deep vein thrombosis or pulmonary embolism may be taking high dose apixaban or rivaroxaban for the first 1 to 3 weeks of treatment. It would be advisable to delay any dental procedures likely to cause bleeding until the patient is taking the standard doses.