Is it safe for a 76-year-old patient with GERD, on Eliquis (apixaban) for a PE, to take Celebrex (celecoxib) after a total knee replacement?

Safety of Celebrex with Apixaban After Total Knee Replacement

Celebrex (celecoxib) should be avoided in this 76-year-old patient with GERD who is on Eliquis (apixaban) for PE after total knee replacement due to increased bleeding risk.

Bleeding Risk Considerations

The combination of an anticoagulant like apixaban with NSAIDs like celecoxib significantly increases the risk of bleeding complications:

• Apixaban is a direct factor Xa inhibitor used for treatment of pulmonary embolism (PE) and carries an inherent bleeding risk 1
• NSAIDs, including celecoxib, can increase bleeding risk through antiplatelet effects 2
• The FDA label for apixaban specifically warns about increased bleeding risk when combined with drugs that affect hemostasis, including NSAIDs 1
• The patient's advanced age (76 years) further increases bleeding risk, as the one-year risk of GI bleeding with NSAIDs is approximately 1 in 110 adults older than 75 2

GERD Considerations

This patient's GERD is an additional concern:

• NSAIDs, including celecoxib, can exacerbate GERD symptoms and increase risk of GI complications 2
• While celecoxib has a lower risk of GI bleeding compared to traditional NSAIDs, the combination with apixaban negates this advantage 2
• The American College of Chest Physicians guidelines note that the risk of GI bleeding increases three to six times if NSAIDs are used with anticoagulants 2

Alternative Pain Management Options

For post-total knee replacement pain management in this patient:

1. Acetaminophen: First-line alternative for pain control without antiplatelet effects
2. Tramadol: Can be considered for moderate pain if acetaminophen is insufficient
3. Physical therapy modalities: Ice, elevation, and appropriate rehabilitation exercises
4. Local anesthetic techniques: If available and appropriate

Special Considerations for This Patient

The patient has multiple risk factors that compound bleeding concerns:

• Recent total knee replacement surgery (tissue healing phase)
• Active anticoagulation for PE (therapeutic dosing of apixaban)
• Advanced age (76 years)
• GERD (increased risk of upper GI complications)

Monitoring Recommendations

If pain control absolutely necessitates an NSAID despite these risks:

• Use the lowest effective dose for the shortest duration possible
• Consider gastroprotection with a proton pump inhibitor
• Monitor closely for signs of bleeding (bruising, tarry stools, hematemesis)
• Monitor for worsening GERD symptoms
• Educate the patient about bleeding warning signs

The combination of apixaban and celecoxib represents a significant bleeding risk that outweighs the potential benefits for pain management in this particular patient with multiple risk factors.