Safety of Using Voltaren Gel with Eliquis
Concurrent use of Voltaren gel (diclofenac) with Eliquis (apixaban) should be approached with caution due to potential increased bleeding risk, though topical NSAIDs have less systemic absorption than oral formulations. 1
Mechanism of Potential Interaction
- Diclofenac, even in topical gel form, can be systemically absorbed and may increase bleeding risk when combined with anticoagulants like apixaban 2
- NSAIDs like diclofenac can cause cardiovascular thrombotic events, myocardial infarction, and stroke, which may compound risks in patients already taking anticoagulants 1
- NSAIDs also increase the risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation 1
Clinical Considerations
- While topical diclofenac has lower systemic absorption than oral NSAIDs, case reports have documented upper gastrointestinal hemorrhage associated with cutaneous application of diclofenac gel 2
- Apixaban is associated with bleeding risk on its own, and any medication that may increase this risk should be used cautiously 3
- Many patients lack knowledge about potential interactions between over-the-counter products and direct oral anticoagulants like apixaban 4
Risk Assessment and Recommendations
For patients requiring pain management while on apixaban:
- Acetaminophen is recommended as a safer first-line alternative due to its lack of antiplatelet effects 5
- Non-pharmacological pain management strategies should be employed when possible 5
- If stronger analgesia is needed, consider short-term opioid medications under close supervision rather than NSAIDs 5
If diclofenac gel must be used:
- Apply to the smallest affected area possible
- Use the lowest effective dose for the shortest duration necessary
- Monitor closely for signs of bleeding
- Educate patients about potential interaction risks and bleeding symptoms 4
Special Considerations
- Elderly patients are at greater risk for serious gastrointestinal events with NSAIDs 1
- Patients with cardiovascular disease or risk factors may be at greater risk when using NSAIDs 1
- Renal impairment can further increase bleeding risk by delaying clearance of both medications 5
Monitoring
Watch for signs of bleeding including:
- Unusual bruising
- Nosebleeds
- Blood in urine or stool
- Coffee-ground vomitus
- Severe headache (potential intracranial bleeding)
In a study comparing bleeding risks with different anticoagulants, apixaban was associated with lower major bleeding risk compared to warfarin or rivaroxaban 6, but this advantage may be diminished when combined with NSAIDs
Remember that while the risk may be lower with topical versus oral NSAIDs, systemic absorption still occurs and caution is warranted when combining with anticoagulants.