Can I use Voltaren (Diclofenac) while taking Eliquis (Apixaban)?

Concurrent Use of Voltaren (Diclofenac) and Eliquis (Apixaban)

Concurrent use of Voltaren (diclofenac) with Eliquis (apixaban) is not recommended due to significantly increased bleeding risk when these medications are combined. 1

Mechanism of Interaction and Bleeding Risk

Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that increases cardiovascular risk and bleeding risk through several mechanisms:

• NSAIDs inhibit platelet aggregation, which can potentiate the anticoagulant effect of apixaban 1
• Diclofenac specifically has been associated with a higher cardiovascular risk compared to other NSAIDs, with a relative risk of 1.63 (95% CI: 1.12-2.37) for vascular events 1
• When combined with anticoagulants like apixaban, the risk of serious gastrointestinal bleeding is substantially increased 2

Evidence-Based Recommendations

The American Heart Association scientific statement on NSAIDs highlights that diclofenac carries a black box warning regarding cardiovascular risk, which is particularly concerning when combined with anticoagulants 1.

Research shows that:

• 33% of patients on apixaban take at least one over-the-counter product with potentially serious interactions daily or most days 2
• Approximately 66% of patients are uncertain or incorrect about the potential for increased bleeding from combining NSAIDs with apixaban 2

Alternative Approaches

If pain management is necessary while on apixaban, consider:

1. Non-pharmacological approaches:

   • Physical therapy
   • Heat or cold therapy
   • Rest and activity modification

2. Alternative medications with lower bleeding risk:

   • Acetaminophen (Tylenol) - preferred first-line option
   • Topical analgesics that have minimal systemic absorption

Special Considerations

• If diclofenac must be used (in rare situations where benefits outweigh risks):

  • Use the lowest effective dose for the shortest duration possible
  • Consider temporary dose reduction of apixaban (though this should be discussed with the prescribing physician)
  • Monitor closely for signs of bleeding (bruising, nosebleeds, blood in urine/stool, unusual headaches)

• Patients over 80 years old require particularly careful monitoring due to:

  • Increased bleeding risk
  • Potentially reduced renal function affecting drug clearance
  • Higher stroke risk if anticoagulation is compromised 3

Conclusion

The combination of Voltaren (diclofenac) and Eliquis (apixaban) significantly increases bleeding risk without providing additional benefit in terms of thromboembolism prevention. Acetaminophen remains the safest analgesic option for patients on apixaban therapy.