Can a person take Eliquis (apixaban) and indomethacin together?

Concurrent Use of Eliquis (Apixaban) and Indomethacin

Concurrent use of Eliquis (apixaban) and indomethacin is not recommended due to significantly increased bleeding risk when NSAIDs are combined with anticoagulants.

Mechanism of Interaction

The combination of apixaban and indomethacin presents a concerning drug interaction for several reasons:

• Additive anticoagulant effects: Both medications affect hemostasis through different mechanisms 1
• Increased bleeding risk: NSAIDs like indomethacin can cause gastric erosions and impair platelet function 2
• Documented risk: Research shows that NSAID use with anticoagulants significantly increases bleeding events:
  • Major bleeding rates increase to 6.5 per 100 patient-years with NSAID-anticoagulant combination versus 2.0 per 100 patient-years with anticoagulant alone (HR 2.37) 2
  • Clinically relevant bleeding increases to 37.5 per 100 patient-years with the combination versus 16.6 per 100 patient-years with anticoagulant alone (HR 1.77) 2

Clinical Decision Algorithm

1. Assess necessity of both medications:

   • If indomethacin is being used for pain management, consider alternative non-NSAID analgesics (acetaminophen)
   • If anti-inflammatory effects are needed, consider lowest effective dose for shortest duration

2. If concurrent use cannot be avoided:

   • Monitor closely for signs of bleeding (skin bruising, hematuria, melena) 3
   • Consider gastroprotection with proton pump inhibitors
   • Monitor for changes in anticoagulant effect

3. Consider alternative anticoagulants:

   • If NSAID therapy is absolutely necessary and long-term, edoxaban may have fewer interactions than apixaban 4
   • Low molecular weight heparin might be considered in high-risk patients 4

Important Warnings and Precautions

• The FDA label for apixaban specifically warns that "concomitant use of drugs affecting hemostasis increases the risk of bleeding. These include... nonsteroidal anti-inflammatory drugs (NSAIDs)" 1
• Patients often lack knowledge about OTC product interactions with apixaban, with approximately 66% being uncertain or incorrect about the potential for increased bleeding from combining NSAIDs and apixaban 5
• Spontaneous skin bruising and hematuria have been documented in case reports of patients using anticoagulants with NSAIDs 3

Monitoring Recommendations

If concurrent use is unavoidable:

• Watch for signs of bleeding (bruising, bleeding gums, dark stools, hematuria)
• Be aware that standard laboratory measures like prothrombin time and activated partial thromboplastin time are not sensitive enough to detect apixaban's anticoagulant effect 6
• Consider more frequent clinical follow-up during periods of concurrent use

Bottom Line

The combination of apixaban and indomethacin significantly increases bleeding risk and should generally be avoided. Alternative pain management strategies that don't involve NSAIDs should be strongly considered for patients on apixaban.