Can I take 10 ml of fish oil daily while on clopidogrel (Plavix) and apixaban (Elequis)?

Can You Take 10 mL Fish Oil Daily with Clopidogrel and Apixaban?

Yes, you can safely take 10 mL of fish oil daily while on clopidogrel and apixaban—high-quality evidence demonstrates no increased bleeding risk when fish oil is combined with dual antiplatelet therapy, and guideline data confirm no pharmacokinetic interaction between fish oil and NOACs like apixaban. 1, 2

Evidence for Safety of Fish Oil with Antiplatelet and Anticoagulant Therapy

No Pharmacokinetic Interaction with Apixaban

• The 2018 European Heart Rhythm Association guideline explicitly states that there are no pharmacokinetic data on fish oil supplements for any of the NOACs (including apixaban), but interaction is unlikely 1
• This means fish oil does not affect apixaban blood levels through drug metabolism pathways (CYP3A4 or P-glycoprotein) 1

Proven Safety with Dual Antiplatelet Therapy

• A retrospective study of 182 patients taking high-dose fish oil (mean 3 grams daily) combined with aspirin and clopidogrel found only 1 major bleeding episode in the treatment group versus 0 in controls taking aspirin and clopidogrel alone (p = 1.0) 2
• Minor bleeding occurred in 2.2% of patients on triple therapy (fish oil + aspirin + clopidogrel) versus 3.9% in controls, with no statistically significant difference (p = 0.5) 2
• The study concluded that high-dose fish oil is safe in combination with aspirin and clopidogrel and does not increase bleeding risk 2

Guideline Perspective on Bleeding Risk

• The American College of Cardiology states that prescription omega-3 products at doses of 1.8-4 grams daily do not significantly increase the risk of bleeding, even when combined with antiplatelet agents or anticoagulants 3
• However, shared decision-making discussions are recommended for patients with underlying fibrinogen dysfunction or those taking antiplatelet/anticoagulant agents, with consideration of monitoring PT/aPTT 3

Important Caveats About Your Specific Regimen

You Are on Triple Antithrombotic Therapy

• Your combination of clopidogrel (antiplatelet) + apixaban (anticoagulant) already carries significant bleeding risk 4
• The European Society of Cardiology recommends the lowest prescribed dose combination of clopidogrel 75 mg daily plus apixaban 2.5 mg twice daily for patients requiring dual therapy 4
• Dual therapy with clopidogrel and apixaban significantly increases bleeding risk compared to monotherapy 4

Fish Oil Dose Considerations

• Most over-the-counter fish oil products contain insufficient EPA and DHA per serving—the average is only 697 mg per serving, requiring multiple servings to reach therapeutic doses 5
• 10 mL of fish oil typically provides approximately 2-3 grams of combined EPA and DHA, depending on the product concentration 5
• This dose falls within the range studied for safety (mean 3 grams) in patients on dual antiplatelet therapy 2

Practical Recommendations

Monitoring Strategy

• Monitor for signs of bleeding: easy bruising, prolonged bleeding from cuts, blood in urine or stool, unusual nosebleeds, or bleeding gums 3
• Consider checking PT/aPTT at baseline and periodically if you have additional bleeding risk factors (age ≥75 years, prior GI bleeding, renal impairment) 3
• Report any bleeding episodes immediately to your prescribing physician 4

Risk Factors That Increase Bleeding Concern

• Advanced age (≥75 years) further elevates baseline bleeding risk with antiplatelet agents 6
• Prior history of gastrointestinal bleeding markedly increases the likelihood of serious bleeding 6
• Concurrent use of NSAIDs or corticosteroids compounds bleeding risk 6

Product Quality Matters

• Use pharmaceutical-grade fish oil products with verified EPA and DHA content, as over-the-counter products have variable quality and potential contamination 3
• Prescription omega-3 products are preferred for cardiovascular indications, though not required for safety when combined with your medications 3

Duration of Your Dual Therapy

• Discontinuation of antiplatelet treatment (clopidogrel) in patients treated with oral anticoagulation (apixaban) should be considered at 12 months 4
• Beyond 12 months, oral anticoagulation alone is superior to combination therapy for most patients, as bleeding risk outweighs additional thrombotic protection 4
• Discuss with your cardiologist whether you still require both clopidogrel and apixaban, as this affects your overall bleeding risk profile 4

Bottom Line

The evidence strongly supports that fish oil at your proposed dose (10 mL daily, approximately 2-3 grams EPA+DHA) does not add meaningful bleeding risk to your regimen of clopidogrel and apixaban. However, your baseline bleeding risk is already elevated due to dual antithrombotic therapy, so vigilant monitoring for bleeding symptoms is essential. Ensure you are using a quality fish oil product and discuss the duration of your clopidogrel therapy with your physician, as prolonged dual therapy beyond 12 months may not be necessary. 1, 3, 4, 2