What supplements should a patient taking Clopidogrel (antiplatelet medication) and Eliquis (Apixaban, anticoagulant) avoid to minimize the risk of bleeding?

Supplements to Avoid While Taking Clopidogrel and Eliquis

Patients taking clopidogrel and apixaban (Eliquis) must avoid garlic, ginkgo biloba, turmeric, ginger, fish oil (high doses), St. John's wort, and vitamin E supplements due to increased bleeding risk. 1, 2

High-Risk Supplements That Increase Bleeding

Strongly Contraindicated Supplements

• Garlic supplements are strongly associated with surgical bleeding independent of anticoagulants and potentiate bleeding when combined with antiplatelet/anticoagulant therapy 2, 3
• Ginkgo biloba significantly increases bleeding risk when combined with antiplatelet agents like clopidogrel, with documented cases of hemorrhage 2, 3, 4
• Hawthorn is strongly associated with surgical bleeding independent of anticoagulants 2

Supplements With Documented Bleeding Risk on Anticoagulants

• Turmeric/curcumin is associated with bleeding risk in patients on anticoagulants 2
• Ginger has conflicting evidence but multiple reports suggest increased bleeding risk when combined with anticoagulants 2, 3
• Chamomile is associated with bleeding risk in anticoagulated patients 2
• Fenugreek increases bleeding risk when combined with anticoagulants 2
• Bilberry is associated with bleeding complications in anticoagulated patients 2
• Milk thistle and peppermint are associated with bleeding risk on anticoagulants 2

Supplements With Moderate Risk

• Chondroitin-glucosamine is associated with bleeding risk in patients on anticoagulants 2
• Melatonin increases bleeding risk when combined with anticoagulant therapy 2
• Cordyceps sinensis, echinacea, and aloe vera are loosely associated with surgical bleeding 2

Supplements That May Interfere With Clopidogrel Metabolism

• St. John's wort has conflicting evidence but may alter drug metabolism and bleeding risk 2
• Cranberry has conflicting evidence regarding bleeding risk 2

Supplements Generally Considered Safe

• Fish oil at standard doses is not associated with increased bleeding risk, though high doses (>3g/day) warrant caution 2
• Ginseng is not associated with bleeding in most studies, though some older reports suggest caution 2, 3
• Saw palmetto is not associated with bleeding 2

Critical Management Recommendations

Timing of Discontinuation

• Discontinue all high-risk supplements at least 2 weeks before any surgical or invasive procedure to allow clearance and normalization of hemostatic function 2
• Resume supplements only after achieving adequate hemostasis post-procedure and with physician approval 1

Vitamin K-Containing Supplements

• Avoid supplements containing vitamin K (including passionflower, juniper, verbena officinalis) as they can reduce anticoagulant effectiveness 3

Additional Substances to Avoid

• NSAIDs (including chronic aspirin use beyond prescribed antiplatelet therapy) significantly increase bleeding risk 5, 1
• Anticoagulants should not be combined with clopidogrel and apixaban without explicit physician direction due to dramatically increased bleeding risk 5, 1
• Steroids increase gastrointestinal bleeding risk when combined with antiplatelet/anticoagulant therapy 5

Common Pitfalls to Avoid

Never assume "natural" means safe - patients often fail to report herbal supplement use to physicians, creating dangerous drug interactions 2, 3

The FDA label for clopidogrel explicitly warns that concomitant use of drugs increasing bleeding risk (including many supplements) significantly elevates hemorrhage risk 1

Bleeding manifestations to monitor for include: unexplained bruising, prolonged bleeding from minor cuts, blood in urine (pink/red/brown), black tarry stools, nosebleeds, bleeding gums, or any unusual bleeding 1

Alcohol Considerations

• Limit alcohol to one drink per session with abstinent days between to minimize cumulative bleeding risk 6
• Complete abstinence required if: active bleeding, recent major bleeding event, planned surgery, concurrent NSAID use, or liver disease 6