What are the dangers of taking meloxicam (Nonsteroidal Anti-Inflammatory Drug) and apixaban (anticoagulant) together?

From the Guidelines

Taking meloxicam and apixaban together is not recommended due to the significantly increased risk of bleeding complications, which can be life-threatening. When these medications are combined, they can have additive effects on blood clotting mechanisms, raising the risk of serious bleeding events, including gastrointestinal bleeding, bruising, and internal bleeding. Meloxicam, as a nonsteroidal anti-inflammatory drug (NSAID), affects platelet function and reduces protective substances that prevent stomach bleeding, while apixaban inhibits clotting factors to prevent blood clots. This combination can lead to a dangerous situation where blood's ability to clot is severely compromised, particularly in older adults, those with kidney problems, or patients with a history of bleeding disorders 1.

The risk of gastrointestinal bleeding is significantly increased, with a three- to sixfold higher risk when NSAIDs are combined with anticoagulants, as the International Normalized Ratio (INR) can increase by up to 15 percent 1. To mitigate this risk, it is essential to avoid combining these medications whenever possible. If pain relief is necessary while taking apixaban, acetaminophen (Tylenol) is generally considered a safer alternative than NSAIDs like meloxicam.

Some key points to consider when evaluating the risks of combining meloxicam and apixaban include:

• The increased risk of bleeding complications, particularly gastrointestinal bleeding
• The potential for additive effects on blood clotting mechanisms
• The need for close monitoring and potential dosage adjustments if the combination cannot be avoided
• The importance of consulting with a healthcare provider before combining these medications or making any changes to the medication regimen
• The consideration of alternative pain relief options, such as acetaminophen, to minimize the risk of bleeding complications 1.

In real-life clinical practice, it is crucial to prioritize caution and carefully weigh the benefits and risks of combining meloxicam and apixaban, considering the individual patient's medical history, age, and potential risk factors for bleeding complications. The safest approach is to avoid combining these medications whenever possible and to explore alternative treatment options that minimize the risk of bleeding complications.

From the FDA Drug Label

Apixaban can cause bleeding which can be serious and rarely may lead to death. This is because apixaban is a blood thinner medicine that reduces blood clotting You may have a higher risk of bleeding if you take apixaban tablets and take other medicines that increase your risk of bleeding, including: aspirin or aspirin-containing products long-term (chronic) use of nonsteroidal anti-inflammatory drugs (NSAIDs) Certain medicines may increase your risk of bleeding or stroke when taken with apixaban tablets.

The main danger of taking meloxicam (a Nonsteroidal Anti-Inflammatory Drug) and apixaban (an anticoagulant) together is an increased risk of bleeding. This is because both medications can affect blood clotting, and taking them together may increase the likelihood of bleeding complications.

• Bleeding risks may include unexpected bleeding, bleeding that lasts a long time, or bleeding that is severe or cannot be controlled.
• Signs and symptoms of bleeding may include unusual bleeding from the gums, nosebleeds, menstrual bleeding or vaginal bleeding that is heavier than normal, red, pink, or brown urine, or red or black stools. It is essential to inform your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements, to minimize the risk of bleeding or stroke when taking apixaban tablets 2.

From the Research

Dangers of Taking Meloxicam and Apixaban Together

• The use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as meloxicam with anticoagulants like apixaban can increase the risk of bleeding, mainly gastrointestinal 3.
• A study found that the risk of hospitalization for gastrointestinal bleeding was increased after exposure to NSAIDs, with an adjusted odds ratio (OR) of 3.59 (95% CI, 1.58-8.17) in patients receiving anticoagulant therapy 3.
• Another study found that incident NSAID use was associated with an increased risk of major bleeding (hazard ratio [HR], 1.61 [95% CI, 1.11-2.33]) and clinically relevant nonmajor bleeding (HR, 1.70 [95% CI, 1.16-2.48]) in patients with atrial fibrillation taking apixaban or warfarin 4.
• The risk of nongastrointestinal bleeding was also increased after exposure to NSAIDs with an adjusted OR of 2.72 (95% CI, 1.23-6.04) in patients exposed to anticoagulant therapy 3.
• A review of the safety evaluation and effectiveness of apixaban found that it is recommended as a safe, well-tolerated, and effective oral anticoagulant for reducing the risk of ischemic events among atrial fibrillation patients, but may cause dose-related increase in bleeding when combined with dual antiplatelet therapy 5.
• The use of NSAIDs with ongoing antithrombotic treatment after myocardial infarction was associated with increased risk of bleeding and excess thrombotic events, even after short-term treatment 6.
• The safety and efficacy of apixaban versus warfarin appeared not significantly to be altered by NSAID use, but more investigation is needed to confirm these findings 4.
• Physicians should exercise appropriate caution when prescribing NSAIDs for patients who have recently experienced myocardial infarction or are taking anticoagulants like apixaban 6.