Is it safe for a patient with a history of pulmonary embolism, on Eliquis (apixaban), and with low testosterone, to take supplements such as tongkat ali, shilajit, fenugreek, taurine, zinc, and krill oil?

Safety of Supplements with Pulmonary Embolism and Apixaban

Patients with a history of pulmonary embolism who are taking Eliquis (apixaban) should avoid supplements like tongkat ali, fenugreek, and other testosterone-enhancing supplements due to increased risk of thrombotic events. 1, 2

Risk Assessment for Supplement Use with Anticoagulation

• Testosterone-enhancing supplements like fenugreek and tongkat ali have been associated with pulmonary embolism formation due to testosterone-induced polycythemia and increased platelet aggregation 1, 2
• Fenugreek specifically has been documented in case reports to potentially contribute to pulmonary embolism through inhibition of aromatase and 5-alpha-reductase activity, which enhances testosterone levels 1
• Patients with recent pulmonary embolism (within the past year) are at higher risk for recurrence and should be particularly cautious with supplements that may affect coagulation 3
• The European Society of Cardiology recommends regular reassessment of bleeding risk and drug interactions in patients on extended anticoagulation 4

Specific Supplement Considerations

High-Risk Supplements (Should Be Avoided)

• Tongkat ali and fenugreek: Both are testosterone-enhancing supplements that have been associated with thromboembolic events through increased platelet aggregation 1, 2
• Shilajit: Contains fulvic acid and has been reported to have testosterone-boosting effects similar to fenugreek, potentially increasing thrombotic risk 2

Moderate-Risk Supplements (Use with Caution)

• Krill oil: Contains omega-3 fatty acids that may have mild antiplatelet effects, potentially increasing bleeding risk when combined with apixaban 5
• Zinc: While essential for health, high-dose supplementation could potentially interact with anticoagulants; no direct evidence of harm but should be limited to recommended daily allowances 3

Lower-Risk Supplements

• Taurine: Currently no strong evidence suggesting significant interaction with apixaban, though research is limited 3

Monitoring Recommendations

• The European Heart Journal recommends routine re-evaluation at 3-6 months after the acute pulmonary embolism event 3
• For patients receiving extended anticoagulation, regular reassessment of drug tolerance, adherence, renal/hepatic function, and bleeding risk is necessary 3
• Any new supplements should be discussed with healthcare providers before initiation, particularly in patients with history of thromboembolic events 5
• Monitor for signs of bleeding or thrombosis after introducing any new supplement 5

Clinical Decision Algorithm

1. Assess thrombotic risk: Recent PE (within 3 months) represents highest risk period 3
2. Evaluate supplement properties:
   • Testosterone-enhancing supplements (tongkat ali, fenugreek, shilajit) → Avoid 1, 2
   • Supplements with antiplatelet effects (krill oil) → Use with caution 5
   • Supplements without known interactions (taurine) → May be safer but still monitor 3
3. Consider alternatives: For low testosterone, discuss FDA-approved treatments with proper monitoring rather than supplements 3
4. Regular monitoring: If any supplements are used, ensure close follow-up for signs of recurrent thrombosis or bleeding 4

Potential Pitfalls

• Underestimating the thrombotic potential of "natural" supplements, which can significantly impact coagulation 1
• Failing to obtain a complete supplement history from patients, as their use can lead to serious illness 1
• Not recognizing that supplements are poorly regulated and may contain unlisted ingredients that could interact with anticoagulants 1
• Overlooking the potential for testosterone-enhancing supplements to contribute to thrombotic risk through polycythemia and increased platelet aggregation 6, 2