Is there a contraindication for using steroids (corticosteroids) and Eliquis (apixaban) together?

No Absolute Contraindication Between Steroids and Eliquis

There is no absolute contraindication for using corticosteroids and Eliquis (apixaban) together, but this combination significantly increases bleeding risk and requires careful monitoring and risk assessment.

Key Clinical Considerations

Increased Bleeding Risk with Combination Therapy

• Corticosteroid use is a recognized bleeding risk factor when combined with oral anticoagulants like apixaban, particularly in patients with atrial fibrillation 1, 2.

• In a large study of venous thromboembolism patients, corticosteroid use was specifically identified as a high-risk bleeding factor, though apixaban was still used successfully in these patients with lower bleeding rates compared to warfarin 1.

• Among atrial fibrillation patients at high risk of gastrointestinal bleeding (including those on corticosteroids), apixaban demonstrated lower rates of major bleeding compared to warfarin, suggesting it may be a safer anticoagulant choice when steroids are necessary 2.

Evidence from Clinical Trials

• In the ARISTOTLE trial, patients taking NSAIDs (another bleeding risk factor similar to corticosteroids) with apixaban had increased major bleeding (HR 1.61) and clinically relevant non-major bleeding (HR 1.70), but the safety profile of apixaban versus warfarin was not significantly altered by concomitant use 3.

• The combination is used in clinical practice, as evidenced by studies specifically examining high-risk bleeding populations that included corticosteroid users on apixaban 1, 2.

Practical Management Algorithm

When Combination is Necessary:

1. Assess cumulative bleeding risk factors beyond just corticosteroids:

   • Age ≥75 years
   • Chronic kidney disease (stage III-V)
   • Prior gastrointestinal bleeding
   • Concomitant antiplatelet or NSAID use
   • HAS-BLED score ≥3 2

2. If apixaban is chosen over warfarin (which may be preferable):

   • Apixaban shows lower bleeding risk than warfarin even in high-risk populations 1, 2
   • Monitor closely for bleeding signs
   • Consider shorter duration of corticosteroid therapy when possible

3. Avoid dose adjustments of apixaban based solely on corticosteroid use:

   • No specific dose reduction recommendations exist for this combination
   • Standard apixaban dosing applies unless other factors (renal function, age, weight) require adjustment

Important Caveats

• Corticosteroids are explicitly contraindicated with certain immunotherapy agents (interleukin-2, interferon) in oncology settings, but this is unrelated to anticoagulation concerns 4.

• The interaction between corticosteroids and warfarin is well-documented (mean INR increase of 1.24), requiring close monitoring 5. This makes apixaban potentially advantageous as it doesn't require INR monitoring.

• Duration matters: Use corticosteroids for the shortest clinically necessary period to minimize cumulative bleeding risk 6.