Is it okay to take Eliquis (apixaban) and aspirin (acetylsalicylic acid) together?

Combining Eliquis (Apixaban) and Aspirin

Taking Eliquis (apixaban) and aspirin together significantly increases bleeding risk and should generally be avoided unless there is a specific clinical indication requiring combination therapy, such as recent acute coronary syndrome or percutaneous coronary intervention. 1, 2, 3

Bleeding Risk Considerations

Combining anticoagulants like Eliquis with antiplatelet agents like aspirin substantially increases the risk of bleeding complications:

• The FDA label for Eliquis explicitly warns that patients may have a higher risk of bleeding when taking Eliquis with aspirin or aspirin-containing products 3
• The 2024 ESC Guidelines for Atrial Fibrillation state that "bleeding events are more common when antithrombotic agents are combined, and no clear benefit has been observed in terms of prevention of stroke or death" 1
• Bleeding risks include:
  • Unexpected bleeding or bleeding that lasts longer than usual
  • Gastrointestinal bleeding
  • Intracranial hemorrhage (potentially fatal)
  • Increased bruising and prolonged bleeding time

Specific Clinical Scenarios Where Combination May Be Indicated

Combination therapy should be limited to specific clinical situations and for the shortest necessary duration:

1. Recent Acute Coronary Syndrome (ACS) or Percutaneous Coronary Intervention (PCI) 2:

   • For patients with recent ACS or PCI (<6 months), a P2Y12 inhibitor (preferably clopidogrel) with apixaban is recommended
   • For patients 6-12 months post-PCI, either aspirin or clopidogrel with apixaban until 1 year post-PCI
   • After 12 months, antiplatelet therapy should be discontinued, continuing apixaban alone

2. Mechanical Heart Valves: Patients with mechanical heart valves may benefit from combined therapy 4

Duration and Dosing When Combination Is Necessary

When combination therapy is unavoidable:

• Use the lowest effective aspirin dose (81 mg daily) 2
• Aspirin dose should not exceed 100 mg when using combination therapy 2
• Limit the duration of combination therapy to the shortest time necessary 2
• Consider adding a proton pump inhibitor for gastric protection to reduce gastrointestinal bleeding risk 2

Recommendations for Specific Patient Groups

1. Patients with Atrial Fibrillation:

   • For patients with stable coronary artery disease (>12 months after ACS/PCI) and atrial fibrillation, apixaban alone without antiplatelet therapy is recommended 2
   • The ESC guidelines explicitly state that "antiplatelet drugs, such as aspirin and clopidogrel, are not an alternative to OAC. They should not be used for stroke prevention, and can lead to potential harm" 1

2. Patients with Diabetes:

   • Aspirin is not recommended for those at low risk of atherosclerotic cardiovascular disease (such as men and women aged <50 years with diabetes with no other major risk factors) as the low benefit is likely to be outweighed by the risks of bleeding 1

Monitoring and Precautions

If combination therapy is necessary:

• Monitor closely for signs of bleeding
• Be alert for drug interactions that may affect apixaban levels
• Educate patients to recognize and report bleeding symptoms immediately
• Consider temporary interruption of aspirin rather than apixaban if bleeding occurs

Conclusion

The decision to combine Eliquis and aspirin should be carefully considered, weighing the increased bleeding risk against potential benefits. For most patients, Eliquis alone provides sufficient antithrombotic protection, and adding aspirin increases bleeding risk without providing additional benefit. Only use combination therapy when specifically indicated, such as in recent ACS or PCI, and limit the duration to the shortest necessary period.