The People's Perspective on Medicine

Beware Mixing Xarelto or Eliquis and OTC Pain Relievers

Many people with AFib are taking anticoagulants like Eliquis or Xarelto. They must be warned about interactions between these drugs and OTC pain relievers!
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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.

Eliquis and OTC Pain Relievers:

Doctors may perceive Xarelto or Eliquis as less likely to interact with food or other drugs and easier to manage than warfarin. A new survey of more than 700 patients on apixaban found that most of them took some over-the-counter medications, dietary supplements or herbal teas.

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 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 and Xarelto 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).”

“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.”

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.

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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    I started taking turmeric a couple months ago for inflammation. I’ve been on Warfarin for several years. My cardiologist did a couple extra INR tests to see how it would affect my blood. Took one test after 1 week, another after 2 weeks, then again after 1 month. Just had another sheet another month, and INR within the acceptable range. Obviously, not recommending this route for everyone, however, working with my physician was helpful.

    This warning fails to distinguish between OTC pain relievers, i.e., NSAID and non-NSAID pain relievers. Doctors who prescribe Xarelto (which I take for my recurring DVT) and Eliquis, as well as the drug manufacturers, agree that Tylenol or acetaminophen, which is not an NSAID is OK and not dangerous. My own cardiologist also says that taking ibuprofen (like Advil) or naproxen (like Aleve) is also ok if taken occasionally for muscular aches and pains or when you need an anti-inflammatory, which acetaminophen is not. Bottom line: don’t generalize warnings when they apply in only limited situations.

    These new anticoagulants have some serious issues that many physicians are not aware of – especially for eye surgery. I take Xarelto for a genetic clotting condition (Factor 5), and before I had a drainage tube inserted in one eye for relief of glaucoma progression, I was told by two hematologists to stay off the drug for 2 days. Since I was skittish about Xarelto, I doubled that time but still suffered a catastrophic bleed that has left me with only dim light and some vague shapes in that eye and mixed dominance between the eyes that affects my balance. Very bad depth perception.

    Only my retina specialist knew from his own experience that patients need to be off these drugs for ten days for safe eye surgery. It’s not in the literature.

    Please tell us what over-the-counter pain relief we can use if we take Eliquis.

    Yet many are on continued therapies of Coumadin (Warfarin), along with aspirin, both blood thinners. My stance on AFIB: there could be an underlying problem of a nutrient deficiency, especially with magnesium. I have become aware recently of the field of “functional cardiology.” These doctors have found underlying issues that many regular cardiologists missed. When one truly understands how prescription drugs function, then they will hopefully understand why so many side effects follow. What could possibly go wrong?

    You did not mention other OTC meds that we can safely take with eliquis. What is OK?

    This article helps a lot. Neither my doctor or my pharmacist could tell me which herbs to avoid.

    What is the source for the concern re: eliquis and turmeric, ginger, etc. ?? What led you to warn us about this? I’d like to know where to start. I’m taking turmeric and eat a lot of ginger to (I hope) reduce inflammation that may have contributed to my ovarian cancer. Thanks for your help.

    Both turmeric and ginger may increase the likelihood of bleeding, so you should be very cautious about combining them with Eliquis.
    Here’s a link that may be helpful: https://pubmed.ncbi.nlm.nih.gov/23671711-a-review-of-potential-harmful-interactions-between-anticoagulantantiplatelet-agents-and-chinese-herbal-medicines/?from_term=turmeric+anticoagulant&from_pos=3

    Fish oil and Xarelto combined definitely increases the risk of bleeding. It happened to me.

    I take Eliquis. Should I beware ginger in food?

    * Be nice, and don't over share. View comment policy^