What are the risks of using Eliquis (apixaban) with topical Voltaren (diclofenac) in elderly patients?

Safety of Using Eliquis (Apixaban) with Topical Voltaren (Diclofenac) in Elderly Patients

Topical diclofenac can be used with apixaban in elderly patients with caution, as topical NSAIDs have significantly lower systemic absorption compared to oral NSAIDs, reducing the risk of bleeding complications.

Understanding the Medications and Interaction Risk

Apixaban (Eliquis)

• Direct factor Xa inhibitor used for stroke prevention in atrial fibrillation and treatment/prevention of venous thromboembolism
• Carries inherent bleeding risk as an anticoagulant
• Elderly patients are at higher baseline risk for bleeding complications 1

Topical Diclofenac (Voltaren)

• Nonsteroidal anti-inflammatory drug (NSAID) in gel/cream form
• Has significantly lower systemic absorption compared to oral NSAIDs
• Considered safer than oral NSAIDs in terms of systemic effects 1

Potential Interaction Concerns

The FDA label for topical diclofenac specifically mentions potential interactions with anticoagulants:

"Diclofenac and anticoagulants such as warfarin have a synergistic effect on bleeding. The concomitant use of diclofenac and anticoagulants have increased the risk of serious bleeding compared to the use of either drug alone." 2

However, this warning is primarily based on data from oral NSAIDs, not topical formulations.

Evidence Supporting Relative Safety

1. Lower Systemic Absorption: Topical NSAIDs have minimal systemic absorption compared to oral formulations, reducing the risk of drug interactions 1

2. Efficacy in Elderly: Studies show topical diclofenac is effective and generally well-tolerated in elderly patients 3

3. Reduced GI Risk: Topical diclofenac has significantly lower risk of gastrointestinal adverse effects compared to oral NSAIDs 4

Precautions and Monitoring

Despite the relative safety, some precautions are warranted:

• Monitor for bleeding signs: Watch for unexplained bruising, blood in urine/stool, unusual headaches 5
• Limited application area: Apply to a limited body surface area to minimize systemic absorption
• Avoid use on broken skin: This could increase systemic absorption
• Consider renal function: Both medications require dose adjustments for impaired renal function 1

Case Reports of Concern

There have been rare case reports of upper gastrointestinal hemorrhage associated with topical diclofenac application 6. These cases suggest that even with topical application, some systemic absorption occurs that could potentially interact with anticoagulants.

Recommendations for Use

1. Apply topical diclofenac sparingly to the affected area
2. Limit application frequency to the minimum effective dose
3. Monitor for signs of bleeding more frequently than with apixaban alone
4. Consider alternative pain management for patients with:
   • History of GI bleeding
   • Severe renal impairment (CrCl <30 mL/min)
   • Multiple risk factors for bleeding

Alternative Options

If concerned about potential interactions:

• Acetaminophen (paracetamol) for pain relief
• Topical capsaicin for localized pain
• Physical therapy modalities (heat, cold, massage)

Summary

While there is a theoretical risk of increased bleeding when combining apixaban and topical diclofenac in elderly patients, the actual risk appears to be low due to minimal systemic absorption of topical NSAIDs. The benefits of effective pain management with topical diclofenac likely outweigh the risks for most elderly patients on apixaban, provided appropriate monitoring and precautions are implemented.