Vitamins to Avoid When Taking Eliquis (Apixaban)
You do not need to avoid vitamin K or calcium supplements when taking Eliquis, as apixaban works independently of the vitamin K pathway and has no clinically significant interactions with these vitamins. 1
Key Distinction: Eliquis is NOT Like Warfarin
- Vitamin K supplementation is only a concern with warfarin, where it can reduce anticoagulant effectiveness, but not with apixaban or other direct oral anticoagulants (DOACs). 1
- The American Heart Association confirms that calcium supplements with or without vitamin K can be safely taken with Eliquis without clinically significant drug interactions. 1
- Apixaban's mechanism of action does not involve the vitamin K pathway—it directly inhibits Factor Xa, making vitamin K intake irrelevant to its effectiveness. 1, 2
What to Actually Avoid or Use with Extreme Caution
Herbal Supplements - AVOID:
- St. John's Wort must be avoided as it is a strong CYP3A4 and P-glycoprotein inducer that significantly reduces apixaban levels and increases thrombotic risk. 3, 4
- Patients should exercise caution with dietary supplements in general, as many contain substances that can affect apixaban plasma concentrations. 4, 5
Over-the-Counter Pain Medications - AVOID or Use with Extreme Caution:
- NSAIDs (ibuprofen, naproxen) significantly increase bleeding risk when combined with apixaban and should be avoided or used with extreme caution. 1, 3
- In a cross-sectional survey, 28.5% of apixaban patients occasionally used NSAIDs, and approximately 66% were uncertain or incorrect about the increased bleeding risk from this combination. 5
- Acetaminophen is the preferred analgesic for patients on apixaban, as it does not have antiplatelet effects and does not significantly interact with the medication. 1
Antiplatelet Agents - Limit Use:
- Aspirin, clopidogrel, prasugrel, and ticagrelor should be limited to situations where dual or triple therapy is absolutely necessary (mechanical valves, acute coronary syndrome, recent coronary stents), as they increase bleeding risk. 6, 3
- In the AUGUSTUS trial, aspirin caused more bleeding than placebo across all kidney function categories when combined with apixaban. 7
Critical Drug Interactions to Avoid
Strong Dual CYP3A4 and P-gp Inhibitors - CONTRAINDICATED or Dose Reduce:
- Ketoconazole, itraconazole, ritonavir, and clarithromycin can dangerously increase apixaban levels. 1, 3
- The American College of Cardiology recommends reducing apixaban dose by 50% when combined with these agents (if taking 5 mg or 10 mg twice daily), or avoiding them entirely if already on 2.5 mg twice daily. 3
Strong Dual CYP3A4 and P-gp Inducers - AVOID:
- Rifampin, carbamazepine, phenytoin, and St. John's Wort markedly reduce apixaban plasma levels and increase thrombotic risk. 3
Common Pitfall
The most common pitfall is patients and providers incorrectly applying warfarin dietary restrictions (avoiding vitamin K-rich foods like leafy greens) to Eliquis. This is unnecessary and potentially harmful, as patients may avoid nutritious foods without any benefit. 1 Unlike warfarin, which requires consistent vitamin K intake, apixaban patients can eat any foods freely without concern for vitamin K content.