From the Guidelines
Using NSAIDs with Eliquis (apixaban) should generally be avoided whenever possible due to the significantly increased risk of bleeding. If both medications are absolutely necessary, use the lowest effective NSAID dose for the shortest duration possible, and maintain vigilant monitoring for any signs of bleeding such as unusual bruising, nosebleeds, blood in urine or stool, or severe headaches 1. Patients should inform all healthcare providers about taking Eliquis before any NSAID is prescribed, including over-the-counter options like ibuprofen (Advil, Motrin) and naproxen (Aleve). For pain relief, acetaminophen (Tylenol) is typically a safer alternative that doesn't increase bleeding risk. The increased bleeding risk occurs because Eliquis prevents blood clotting by inhibiting Factor Xa in the coagulation cascade, while NSAIDs inhibit platelet aggregation and can damage the stomach lining, creating a dangerous combination effect 1.
Some key points to consider when using NSAIDs with Eliquis include:
- Avoiding NSAIDs in persons with a history of NSAID-associated upper GI tract bleeding or combining NSAID with a PPI or misoprostol to reduce the risk of GI bleeding 1
- Using NSAIDs with caution in persons with hypertension, as they can worsen hypertension and increase the risk of cardiovascular complications 1
- Avoiding NSAIDs in persons with renal disease, as they can impair renal function and increase the risk of bleeding 1
- Informing patients to avoid alcohol while taking this combination, as it further increases bleeding risk, and to wear medical alert identification indicating they take an anticoagulant.
It is essential to weigh the benefits and risks of using NSAIDs with Eliquis and to consider alternative pain relief options to minimize the risk of bleeding and other complications 1.
From the FDA Drug Label
WARNINGS CARDIOVASCULAR EFFECTS Cardiovascular Thrombotic Events Clinical trials of several COX-2 selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, including myocardial infarction (MI) and stroke, which can be fatal
Gastrointestinal Effects - Risk of Ulceration, Bleeding, and Perforation NSAIDs, including ibuprofen tablets can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal
The use of NSAIDs with Eliquis (Apixaban) may increase the risk of:
- Cardiovascular thrombotic events, including myocardial infarction and stroke
- Gastrointestinal adverse events, including bleeding, ulceration, and perforation of the stomach or intestines To minimize the potential risk, use the lowest effective dose of NSAIDs for the shortest duration possible and monitor patients for signs of cardiac ischemia and gastrointestinal events 2.
From the Research
Precautions with NSAIDs and Eliquis (Apixaban)
When using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) with Eliquis (Apixaban), several precautions should be considered:
- The risk of bleeding, particularly gastrointestinal bleeding, is increased when NSAIDs are used concomitantly with anticoagulants like Eliquis 3.
- The use of NSAIDs with anticoagulants can lead to a higher risk of hospitalization for bleeding, with an adjusted odds ratio (OR) of 3.59 for gastrointestinal bleeding and 2.72 for non-gastrointestinal bleeding 3.
- Proton pump inhibitors (PPIs), often prescribed to reduce NSAID-induced gastrointestinal adverse events, may potentiate the gastrointestinal risks associated with NSAIDs [(4,5)].
Patient-Specific Considerations
Certain patient populations may be at higher risk for adverse effects when using NSAIDs with Eliquis:
- Patients with a history of renal disease, asthma, or prior myocardial infarction who are receiving antithrombotic therapy may be at increased risk 6.
- Patients with infectious diseases should use NSAIDs with caution, as they may confer risk in some situations 7.
Safe Use of NSAIDs with Eliquis
To minimize risks, NSAIDs should be used at the most effective dose and for the shortest duration possible, ideally 10 days or fewer 6. It is essential to weigh the benefits and risks of using NSAIDs with Eliquis and to consider alternative pain management options when necessary [(5,7)].