Are Red Yeast Rice with Coenzyme Q10 (COQ10), Milk Thistle, and Alpha Lipoic Acid, as well as Beta-Sitosterol Plant Sterols with CardioAid, safe to take with Eliquis (Apixaban)?

Safety of Supplements with Eliquis (Apixaban)

The supplements you listed—Red Yeast Rice with CoQ10, Milk Thistle, Alpha Lipoic Acid, and Beta-Sitosterol Plant Sterols—can generally be taken with Eliquis, but Red Yeast Rice requires specific caution due to its statin-like properties and potential drug interactions.

Red Yeast Rice with CoQ10

Red Yeast Rice poses the primary concern in this combination due to its active ingredient, monacolin K, which is chemically identical to lovastatin (a statin medication). While Red Yeast Rice itself does not directly interact with apixaban's CYP3A4 or P-glycoprotein pathways 1, the concern lies in:

• No documented interaction with apixaban metabolism: Apixaban is metabolized primarily through CYP3A4 and P-glycoprotein transporters 1, and Red Yeast Rice does not significantly affect these pathways
• CoQ10 is safe with apixaban: CoQ10 has no known interactions with CYP3A4 or P-gp pathways that would affect apixaban levels 2
• Monitor for muscle symptoms: If you develop muscle pain or weakness while taking this combination, report it immediately, as this could indicate statin-related myopathy 1

Milk Thistle

Milk Thistle is considered safe with Eliquis based on available evidence:

• Low likelihood of drug interactions: Milk Thistle has a low probability of clinically significant drug interactions and can safely be taken with most medications 3
• No documented apixaban interaction: There is no evidence that milk thistle affects CYP3A4 or P-glycoprotein in a clinically meaningful way that would alter apixaban levels 3

Alpha Lipoic Acid

Alpha Lipoic Acid appears safe with apixaban:

• No anticoagulant pathway interaction: Alpha lipoic acid functions primarily as an antioxidant and does not interact with the metabolic pathways (CYP3A4, P-gp) that affect apixaban 4, 5
• No bleeding risk enhancement: Unlike NSAIDs or antiplatelet agents, alpha lipoic acid does not independently increase bleeding risk 6

Beta-Sitosterol Plant Sterols (with CardioAid)

Plant sterols are safe with Eliquis:

• FDA-recognized as safe: Phytosterols have "generally recognized as safe" (GRAS) status and are well-tolerated 1
• No apixaban interaction: Plant sterols work by displacing cholesterol in the intestinal tract and do not affect CYP3A4 or P-glycoprotein pathways 1
• Timing consideration: If you are taking bile acid sequestrants (cholestyramine, colestipol, colesevelam), separate plant sterol intake by 2-4 hours to avoid binding 1

Critical Monitoring Points

Watch for these warning signs while on Eliquis with any supplements:

• Bleeding symptoms: Unusual bruising, prolonged bleeding from cuts, black/tarry stools, blood in urine, or coughing up blood 6
• Regular monitoring: Continue standard bleeding surveillance regardless of supplement use 2
• Disclosure to all providers: Always inform healthcare providers about all supplements, as most patients do not voluntarily disclose supplement use 7, 3

Key Pitfalls to Avoid

• Do not combine with NSAIDs: Avoid adding ibuprofen, naproxen, or other NSAIDs to this regimen, as this substantially increases bleeding risk 6
• Avoid triple therapy: Never combine Eliquis with both an NSAID and an antiplatelet agent (aspirin, clopidogrel) 6
• Consider individual factors: Age, renal function (creatinine clearance), and other medications must be factored into overall safety assessment 2
• Beware of strong CYP3A4/P-gp inhibitors: If you start medications like ketoconazole, clarithromycin, or ritonavir, your Eliquis dose may need adjustment 1