What is the interaction between ginger and Eliquis (apixaban)?

Ginger and Eliquis (Apixaban) Interaction: Increased Bleeding Risk

Patients taking Eliquis (apixaban) should avoid ginger supplements due to the increased risk of bleeding complications. 1 This interaction poses a potentially serious risk that requires careful management.

Mechanism of Interaction

• Ginger contains constituents that have antiplatelet effects, with multiple components shown to inhibit platelet aggregation in vitro 1
• Ginger may slow blood clotting, creating potential drug-drug interactions with anticoagulants like apixaban 1
• This additive antiplatelet effect can enhance the anticoagulant action of Eliquis, which works by inhibiting factor Xa and preventing the conversion of prothrombin to thrombin 2

Clinical Evidence and Reported Cases

• There is documented evidence of fatal bleeding when herbal products like ginger are combined with direct-acting oral anticoagulants (DOACs) 3
• A case report described an 80-year-old man on dabigatran (another DOAC) who developed fatal gastrointestinal bleeding after consuming a boiled mixture of ginger and cinnamon 3
• Another case report documented ginger-associated overanticoagulation with phenprocoumon (a vitamin K antagonist), resulting in an elevated INR up to 10 and epistaxis 4

Recommendations for Patients on Eliquis

• Healthcare providers should specifically ask patients about ginger consumption, including supplements, teas, and foods with high ginger content 1
• The Society for Perioperative Assessment and Quality Improvement recommends holding ginger supplements for at least 2 weeks before surgery due to its inhibition of thromboxane synthetase and decreased platelet aggregation 1
• Patients who have been taking both ginger and Eliquis should be monitored for signs of increased bleeding, such as:
  • Unusual bruising or petechiae 1
  • Prolonged bleeding from cuts 1
  • Nosebleeds or gum bleeding 1

Management of Concurrent Use

• If a patient is found to be taking both ginger and Eliquis:
  • Discontinue ginger supplements immediately 1
  • Monitor for signs of bleeding 1
  • In case of significant bleeding, temporary discontinuation of Eliquis and supportive care may be necessary 1
• For patients requiring pain management (a common reason for ginger use), acetaminophen is generally considered a safer alternative for patients on anticoagulants like Eliquis 1

Important Considerations for Healthcare Providers

• Many patients do not report herbal supplement use to their healthcare providers, considering them "natural" and therefore safe 5
• The scientific community must take into account adverse events caused by interaction between herbal medicine and conventional therapy 5
• Patients must be informed of the specific dangers of these preparations, particularly when taking anticoagulants 5

This interaction between ginger and Eliquis represents a clinically significant risk that warrants careful consideration in anticoagulant management. While some studies suggest ginkgo and ginger do not appear to interact with warfarin at modest doses 2, the more recent evidence and guidelines specifically addressing DOACs like apixaban indicate a concerning risk profile when combined with ginger 1, 3.