From the FDA Drug Label
Concomitant use of ACE inhibitors and/or angiotensin II receptor antagonists may increase the risk of renal impairment, particularly in volume-depleted patients Reports suggest that NSAIDs may diminish the antihypertensive effect of ACE inhibitors and/or angiotensin II receptor antagonists. The effects of warfarin and NSAIDs, in general, on GI bleeding are synergistic, such that the users of both drugs together have a risk of serious GI bleeding higher than the users of either drug alone. Although these results do not indicate a significant interaction between ketorolac tromethamine and warfarin or heparin, the administration of ketorolac tromethamine to patients taking anticoagulants should be done extremely cautiously, and patients should be closely monitored Epidural or spinal hematomas may occur in patients treated with apixaban who are receiving neuraxial anesthesia or undergoing spinal puncture. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: • use of indwelling epidural catheters • concomitant use of other drugs that affect hemostasis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants
Ketorolac is not appropriate for a patient taking Eliquis (Apixaban) due to the increased risk of bleeding and spinal/epidural hematomas. The concomitant use of NSAIDs, such as ketorolac, and anticoagulants, such as apixaban, should be done with extreme caution and close monitoring. The benefits and risks should be carefully considered before initiating ketorolac in a patient taking apixaban. 1 2
From the Research
Ketorolac is generally not appropriate for patients taking Eliquis (apixaban) due to the increased risk of bleeding complications. The combination of these two medications can significantly increase the risk of bleeding because both affect blood clotting through different mechanisms. Apixaban is an anticoagulant that directly inhibits factor Xa in the clotting cascade, while ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation and can cause gastric irritation 3. When used together, this dual effect on hemostasis can lead to dangerous bleeding complications, including gastrointestinal bleeding or intracranial hemorrhage. For pain management in patients on apixaban, acetaminophen (Tylenol) is typically a safer alternative. If stronger pain control is needed, consultation with the prescribing physician is recommended to evaluate the risk-benefit ratio and possibly consider temporary dose adjustments or monitoring strategies. In emergency situations where ketorolac might be considered essential, healthcare providers should carefully assess bleeding risk factors and monitor the patient closely for any signs of bleeding, as suggested by guidelines on managing anticoagulation and anti-platelet therapy before surgery 4. It's also worth noting that the safety profile of ketorolac has been studied in specific populations, such as patients with sickle cell disease, where it was found to be effective in pain control without significant adverse events in short-term use 5. However, the primary concern with using ketorolac in patients taking Eliquis remains the increased risk of bleeding, which should be carefully weighed against the potential benefits of its use 6, 7.