Can I take aspirin (acetylsalicylic acid) and Eliquis (apixaban) together?

Should You Take Aspirin and Eliquis Together?

You should not take aspirin and Eliquis (apixaban) together unless you have a specific medical indication that requires dual therapy, as this combination significantly increases bleeding risk without providing additional stroke prevention benefits for most patients with atrial fibrillation.

When Combination Therapy Is NOT Recommended

• The European Society of Cardiology (ESC) explicitly states that adding antiplatelet treatment to anticoagulation is not recommended in patients with atrial fibrillation to prevent recurrent embolic stroke 1
• Antiplatelet drugs like aspirin should not be used for stroke prevention in atrial fibrillation patients, as they can lead to potential harm 1
• The FDA label for apixaban (Eliquis) specifically warns that coadministration with aspirin increases the risk of bleeding 2

Bleeding Risks of Combination Therapy

• Combining Eliquis with aspirin significantly increases bleeding risk:
  • In the ARISTOTLE trial, concomitant use of aspirin increased bleeding risk on apixaban from 1.8% per year to 3.4% per year 2
  • A 2021 study found that patients taking both DOAC and aspirin experienced more bleeding events (31.6 vs 26.0 bleeds per 100 patient-years) and had higher hospitalization rates (9.1 vs 6.5 admissions per 100 patient-years) compared to DOAC monotherapy 3
  • While taking Eliquis, you may already bruise more easily and bleeding may take longer to stop 2

Specific Situations Where Combination May Be Indicated

Combination therapy with Eliquis and aspirin is only appropriate in limited clinical scenarios:

1. Recent Acute Coronary Syndrome (ACS) or Percutaneous Coronary Intervention (PCI):

   • If you've recently had a stent placed or heart attack, triple therapy (oral anticoagulant + P2Y12 inhibitor + aspirin) should be limited to 30 days or less 4
   • After this initial period, aspirin should be discontinued while continuing P2Y12 inhibitor (preferably clopidogrel) and anticoagulation 4

2. Mechanical Heart Valves:

   • Patients with prosthetic heart valves who have had a transient ischemic attack may benefit from combination therapy 4

3. Specific Vascular Disease:

   • In select patients with stable coronary or peripheral artery disease, low-dose rivaroxaban (2.5mg twice daily) plus aspirin may be considered, but this is different from the standard Eliquis dosing for atrial fibrillation 1

Important Considerations If Combination Therapy Is Required

If your doctor determines you need both medications:

• Use the lowest possible aspirin dose (typically 81mg) 1, 4
• Consider a proton pump inhibitor to reduce gastrointestinal bleeding risk 4
• Expect closer monitoring for bleeding complications 4
• Be aware of warning signs of bleeding that require immediate medical attention:
  • Unexpected bleeding that lasts a long time
  • Red, pink, or brown urine
  • Red or black stools
  • Coughing up blood or blood clots
  • Vomiting blood
  • Unexpected pain, swelling, or joint pain
  • Headaches, dizziness, or weakness 2

Conclusion for Most Patients

For the majority of patients on Eliquis for atrial fibrillation without recent ACS/PCI or mechanical heart valves, adding aspirin provides no additional benefit in stroke prevention but significantly increases bleeding risk. If you're currently taking both medications without a clear indication, discuss with your healthcare provider about potentially discontinuing aspirin.