Beware Mixing Xarelto or Eliquis and OTC Pain Relievers (NSAIDs)

Anticoagulant medications are frequently prescribed to people with atrial fibrillation (AFib). This arrhythmia can cause blood clots that might lead to a stroke. AFib used to be treated primarily with the blood thinner warfarin. Now, doctors frequently prescribe newer oral anticoagulants such as apixaban, known as Eliquis or rivaroxaban, sold under the brand name Xarelto. Other anticoagulants include Pradaxa (dabigatran) and Savaysa (edoxaban). Such drugs are also prescribed when doctors fear a patient is at risk for developing blood clots such as deep vein thrombosis (DVT), venous thromboembolism (VTE) or pulmonary embolism (PE). Beware a potentially dangerous interaction, though. When people combine anticoagulants like Eliquis and OTC pain relievers such as naproxen or ibuprofen, there is an increased risk for bleeding (European Heart Journal, Nov. 18, 2024).

NSAIDs and Oral Anticoagulants A Risky Combo:

A new study from Denmark published in the European Heart Journal (Nov. 18, 2024) shows that people taking drugs like Eliquis and OTC pain relievers are at increased risk for bleeding. Tens of millions of Americans swallow NSAIDs such as diclofenac, naproxen, ibuprofen or meloxicam. Some NSAIDs are available over the counter (such as ibuprofen (Advil, etc) and naproxen (Aleve, etc). Others, such as diclofenac or meloxicam have to be prescribed.

The Danish authors conclude:

“In patients treated with oral anticoagulants for VTE [venous thromboembolism], we found that NSAID use, compared with no use, was associated with a more than two-fold increased bleeding rate. This increased rate was observed both in patients treated with DOACs [direct oral anticoagulants] and warfarin and was independent of the type of NSAID used. Although limited by imprecision, diclofenac and naproxen use seemed associated with a higher bleeding rate than ibuprofen use…”

Where Does the Bleeding Occur?

• Digestive tract (gastrointestinal bleeding)
• Intracranial bleeding (brain bleeding)
• Respiratory tract bleeding
• Urinary tract bleeding

Anticoagulants like Eliquis and OTC Pain Relievers: Is This a Real Problem?

Doctors may perceive Xarelto or Eliquis as less likely to interact with food or other drugs and be easier to manage than warfarin. A survey of more than 700 patients on apixaban found that most of them took some over-the-counter medications, dietary supplements or herbal teas (Journal of the American Geriatrics Society, Jan. 2020). Many took NSAID-type drugs such as aspirin, ibuprofen or naproxen that could increase the risk of dangerous bleeding.

Here is what the authors report:

“One‐third (n = 266) of the respondents reported taking at least one OTC product with potentially serious interactions with apixaban either daily or most days… Two‐thirds of respondents were either uncertain or incorrect about the potential increased bleeding risk with combined NSAIDs and apixaban.”

Eliquis and OTC Pain Relievers Containing Aspirin:

This reader wants to know why he wasn’t warned to avoid aspirin:

Q. After being diagnosed with bradycardia (thanks to my Apple watch revealing a slow heart rate), I had a pacemaker implanted. My blood pressure rose, and I was put on an increased dose of lisinopril. The doctor also prescribed furosemide, amlodipine and Eliquis.

I was already taking levothyroxine and using aspirin regularly for aches and pain.

No one warned me about a possible interaction of Eliquis and aspirin. I developed anemia, fluid in the lungs, shortness of breath and misery. The doctors reduced my dose of Eliquis and started talking about heart surgery.

None of the GI tests (colonoscopy, endoscopy and capsule swallowing) showed bleeding anywhere. But before the tests, I stopped taking aspirin, as per instructions. Soon everything was back to normal, and I resumed the regular dose of Eliquis without any harmful effects. I think patients on blood thinners like Eliquis ought to be warned about aspirin.

A. Agreed! No one should take aspirin together with an oral anticoagulant like apixaban (Eliquis) unless a doctor has prescribed it. Aspirin alone can increase the risk of bleeding. Together with an anticoagulant, the danger is even greater.

Eliquis and Herbs:

People are quite confused about the possibility of an interaction between anticoagulants like Eliquis and herbs.

St. John’s wort poses special risks for interactions:

“Of respondents taking St John’s wort, 10.5% incorrectly believed there was a potential increased risk of bleeding if it was combined with apixaban (the interaction results in decreased apixaban concentrations and potentially increases stroke risk), 79.8% were uncertain if there was an interaction, and 9.7% believed there was no interaction.”

But Eliquis and Herbal Teas Must be Safe | Wrong!

Many people think of herbal teas or herbs like ginger or turmeric as completely benign. They may be generally safe for those who are not taking anticoagulants. People taking Eliquis, however, could be making a serious mistake.

The researchers shared their observations:

“We asked 61 of 83 participants who were regularly taking Chinese herbs, ginger, gingko biloba, herbal teas, or turmeric (dietary supplements with potentially serious interactions with apixaban) about whether the product(s) they were taking might lead them to bleed more easily when taken with apixaban. Only three participants agreed that herbal teas might interact with apixaban, and three agreed that turmeric might interact.”

We try to caution people that turmeric as well as ginger and ginkgo may interact with Eliquis. Even fish oil may pose a problem. Eliquis, Xarelto and other anticoagulants pose a serious risk for bleeding.

The official prescribing information warns:

“ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding.

“Concomitant use of drugs affecting hemostasis increases the risk of bleeding. These include aspirin and other antiplatelet agents, other anticoagulants, heparin, thrombolytic agents, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs).”

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“XARELTO increases the risk of bleeding and can cause serious or fatal bleeding. In deciding whether to prescribe XARELTO to patients at increased risk of bleeding, the risk of thrombotic events should be weighed against the risk of bleeding.”

“Concomitant use of other drugs that impair hemostasis increases the risk of bleeding. These include aspirin, P2Y12 platelet inhibitors, dual antiplatelet therapy, other antithrombotic agents, fibrinolytic therapy, non-steroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors.”

You need to know that SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) include antidepressants such as:

• Citalopram (Celexa)
• Desvenlafaxine (Pristiq)
• duloxetine (Cymbalta)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Levomilnacipran (Fetzima)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
• venlafaxine (Effexor)
• Vilazodone (Viibryd)
• Vortioxetine (Trintellix)

The Bottom Line from The People’s Pharmacy:

If you are taking an anticoagulant like Xarelto or Eliquis and OTC pain relievers, always check with the prescribing physician and the dispensing pharmacy about dangerous interactions. As you can see in the FDA’s warning above, pain relievers like aspirin or NSAIDs such as celecoxib, ibuprofen, naproxen or meloxicam could pose serious problems.

If you are also taking dietary supplements or herbs, do some online checking. Your standard-issue health professional may not know about such interactions. Nevertheless, you should always ask!

You can download our *free* Drug Safety Questionnaire + Medical History form. It can be found in the Health eGuide section of this website. Request that your physician and pharmacist fill it out. Then do some additional homework to verify that any OTC drug, herb or dietary supplement you might consider is safe with your anticoagulant.

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