From the Guidelines
Taking NSAIDs and anticoagulants together is generally not recommended due to increased bleeding risk, though in some cases they may be prescribed together with careful monitoring. Common NSAIDs like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin can significantly increase the risk of bleeding when combined with anticoagulants such as warfarin (Coumadin), apixaban (Eliquis), rivaroxaban (Xarelto), or dabigatran (Pradaxa) 1. This interaction occurs because NSAIDs inhibit platelet function and can irritate the stomach lining, while anticoagulants already reduce blood clotting ability. If pain relief is needed while on anticoagulants, acetaminophen (Tylenol) is generally considered a safer alternative. For those who must take both medication types, doctors may prescribe a stomach-protecting medication like a proton pump inhibitor (such as omeprazole) and will likely require more frequent monitoring of blood clotting tests (for warfarin) or signs of bleeding 1. Some key points to consider include:
- The risk of GI bleeding increases three to six times when NSAIDs are used with anticoagulants 1.
- The combined use of NSAIDs and anticoagulants can increase the International Normalized Ratio (INR) by up to 15 percent 1.
- Patients with a history of prior peptic ulcer disease or a prior ulcer complication are at higher risk of GI complications when taking NSAIDs 1.
- Advancing age increases the risk of GI complications by about 4% per year 1. Always inform all healthcare providers about all medications you're taking, and never start an NSAID without consulting the doctor who prescribed your anticoagulant.
From the FDA Drug Label
Caution should be observed when warfarin sodium tablets are administered concomitantly with nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, to be certain that no change in anticoagulation dosage is required In addition to specific drug interactions that might affect PT/INR, NSAIDs, including aspirin, can inhibit platelet aggregation, and can cause gastrointestinal bleeding, peptic ulceration and/or perforation.
NSAIDs and anticoagulants can be taken together, but with caution. The use of NSAIDs, including aspirin, with anticoagulants like warfarin sodium may require monitoring of anticoagulation dosage to prevent bleeding complications. NSAIDs can increase the risk of gastrointestinal bleeding, peptic ulceration, and/or perforation due to their effect on platelet aggregation 2.
From the Research
Interaction between NSAIDs and Anticoagulants
- The provided studies do not directly address the interaction between Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and anticoagulants when taken together 3, 4, 5.
- However, a study published in the Journal of Gastroenterology in 2015 investigated the effects of proton-pump inhibitors (PPIs) on lower gastrointestinal bleeding (LGIB) associated with NSAIDs, aspirin, clopidogrel, and warfarin, and found no significant interactions between PPIs and NSAIDs, aspirin, clopidogrel, or warfarin 6.
- Another study published in 2023 discussed the cardiovascular risk profile of NSAIDs, but did not specifically address the interaction between NSAIDs and anticoagulants 7.
Safety Considerations
- When considering the use of NSAIDs and anticoagulants together, it is essential to weigh the potential benefits against the risks, including the increased risk of gastrointestinal bleeding and cardiovascular events 6, 7.
- The use of PPIs may help reduce the risk of upper gastrointestinal bleeding in patients taking anticoagulants, but the evidence is limited, and more research is needed to fully understand the interactions between these medications 3, 4, 5.
Clinical Implications
- Clinicians should exercise caution when prescribing NSAIDs and anticoagulants together, and consider alternative treatment options or closer monitoring of patients to minimize the risk of adverse events 6, 7.
- Further research is needed to provide more definitive guidance on the safe use of NSAIDs and anticoagulants in combination 3, 4, 5, 6, 7.