Is it safe to take apixaban (anticoagulant) 10mg with boswellia (herbal supplement)?

Apixaban 10mg and Boswellia: Potential Interaction and Safety Concerns

Taking apixaban 10mg with boswellia (Indian frankincense) is not recommended due to potential anticoagulant effects of boswellia that could increase bleeding risk when combined with high-dose apixaban.

Mechanism of Potential Interaction

Apixaban is a direct factor Xa inhibitor that is primarily metabolized via the liver (cytochrome P450 3A4-dependent) with approximately 27% renal elimination 1. At 10mg dosing, which is higher than the standard maintenance dose for most indications, the anticoagulant effect is significant.

Boswellia serrata extract has been shown to have antiplatelet and anticoagulant properties:

• Research demonstrates that boswellia extracts can completely inhibit ADP-induced platelet aggregation at certain concentrations 2
• Boswellia extracts have been shown to significantly prolong prothrombin time (PT) and activated partial thromboplastin time (APTT) 2
• Boswellia can inhibit clotting factors Xa and XIa 2

Clinical Implications

The combination presents several concerns:

1. Additive anticoagulant effects: Both substances independently affect coagulation pathways, with boswellia potentially enhancing the anticoagulant effect of apixaban

2. Increased bleeding risk: Apixaban already carries a bleeding risk that increases with higher doses. In clinical trials, apixaban 10mg twice daily was associated with excess bleeding when studied in acute coronary syndrome patients 1

3. Unpredictable interaction: The herbal supplement's potency can vary between preparations, making the interaction unpredictable

Risk Assessment

Apixaban at 10mg is a high dose that is typically used only for initial treatment of acute venous thromboembolism (10mg twice daily for 7 days) 1. This dose already carries a higher bleeding risk than maintenance dosing. Adding boswellia could:

• Further increase the risk of major bleeding events
• Interfere with the predictable anticoagulant effect that makes apixaban valuable

Recommendations

1. Avoid concurrent use of apixaban and boswellia, particularly at the 10mg dose of apixaban

2. If anticoagulation is required:

   • Use apixaban alone without herbal supplements that affect coagulation
   • Follow established dosing protocols based on indication (typically 5mg twice daily for most indications after initial treatment phase) 1

3. If boswellia is desired for other therapeutic purposes:

   • Consult with healthcare provider before combining with any anticoagulant
   • Consider alternative treatments that don't affect coagulation

Important Considerations

• Major bleeding is a significant adverse event with anticoagulants and is associated with increased morbidity and mortality 3
• Real-world data shows that even at standard doses, apixaban has a bleeding rate of approximately 3.3 per 100 person-years 4
• The high-dose apixaban regimen (10mg twice daily) used in some studies was discontinued early due to excess bleeding 1

Monitoring if Combination Cannot Be Avoided

If for some reason both agents must be used concurrently (not recommended):

• More frequent monitoring for signs of bleeding
• Lower apixaban dose if clinically appropriate
• Be vigilant for signs of bleeding (bruising, blood in urine/stool, unusual bleeding from gums)
• Seek immediate medical attention if bleeding occurs

Remember that herbal supplements are not regulated with the same rigor as prescription medications, and their effects can be variable and unpredictable when combined with potent anticoagulants like apixaban.