Can I take aspirin while on Lexapro (escitalopram) and Eliquis (apixaban)?

Can You Take Aspirin with Lexapro and Eliquis?

You should avoid taking aspirin while on both Lexapro (escitalopram) and Eliquis (apixaban) unless you have a specific compelling indication such as recent stent placement or acute coronary syndrome, as this combination significantly increases your bleeding risk without providing additional benefit for most patients. 1, 2

Why This Combination Is Problematic

Triple Bleeding Risk

• Combining Eliquis (apixaban) with aspirin increases bleeding risk 3-6 fold through additive antiplatelet effects 2
• Adding Lexapro (an SSRI) creates a triple threat because SSRIs independently increase bleeding risk by affecting platelet function 3
• The FDA drug label for apixaban explicitly warns that combining with SSRIs increases bleeding risk and lists this as a major concern 3

Lack of Additional Benefit

• The 2024 European Society of Cardiology guidelines explicitly state that adding antiplatelet treatment to anticoagulation is NOT recommended for stroke prevention in atrial fibrillation patients (Class III recommendation) 1
• Bleeding events are more common when antithrombotic agents are combined, with no clear benefit observed in terms of prevention of stroke or death 1
• In the ARISTOTLE trial, concomitant aspirin use with apixaban increased bleeding from 1.8% per year to 3.4% per year 3

When Triple Therapy Might Be Justified

The only situations where combining aspirin with Eliquis might be appropriate are: 1, 2

• Acute coronary syndrome (within 1-12 months of the event) 1
• Recent coronary stent placement (typically limited to 1-3 months for high bleeding risk patients, up to 12 months for others) 2
• Mechanical heart valve replacement 1

Even in these scenarios, the duration should be minimized and requires close monitoring 1, 2

Specific Bleeding Risks to Monitor

If you must take this combination, watch for these warning signs: 3

• Unusual bleeding from gums or frequent nosebleeds
• Menstrual bleeding heavier than normal
• Red, pink, or brown urine
• Red or black stools (appearing like tar)
• Coughing up blood or blood clots
• Vomiting blood or material that looks like coffee grounds
• Unexpected pain, swelling, or joint pain
• Severe headaches, dizziness, or weakness
• Bruising more easily than usual
• Bleeding that takes longer than usual to stop

Risk Mitigation If Combination Is Necessary

If your physician determines you absolutely need aspirin with Eliquis and Lexapro: 2

• Use the lowest effective aspirin dose (75-100 mg daily) rather than higher doses 2
• Add a proton pump inhibitor (PPI) for gastroprotection, which reduces GI bleeding risk by 68% 2
• Limit the duration of triple therapy to the shortest period necessary (typically 1-3 months) 2
• Monitor closely for any signs of bleeding 3

Common Clinical Pitfall

A major pitfall is that aspirin is often continued with anticoagulants without adequate indication - studies show this occurs frequently in clinical practice despite lack of benefit and increased harm 1, 4

Research demonstrates that adding aspirin to warfarin (another anticoagulant) without clear indication resulted in: 4

• 26.0% bleeding rate at 1 year versus 20.3% with anticoagulant alone
• 5.7% major bleeding versus 3.3% with anticoagulant alone
• Similar thrombosis rates (no additional protection)

Bottom Line Recommendation

Contact your prescribing physician before taking aspirin 3. If you're taking aspirin for cardiovascular protection and are now on Eliquis for atrial fibrillation or venous thromboembolism, the Eliquis alone provides superior stroke prevention compared to aspirin, making the aspirin unnecessary and harmful 1. The AVERROES trial demonstrated that apixaban was superior to aspirin for stroke prevention (HR 0.45) with no significant difference in major bleeding 1.

Discontinue aspirin unless you have one of the specific indications listed above, and discuss with your physician immediately 1, 2.