Can You Use Anti-Inflammatory Drugs With Eliquis?
In our latest question and answer, the pharmacist discusses the use of anti-inflammatory drugs with Eliquis.
Everyone says you shouldn't take Eliquis and ibuprofen together. I hear people say to take Tylenol instead, but Tylenol does nothing for inflammatory pain... it's a useless medication for anything other than fever. Is there any anti-inflammatory that can be used with Eliquis, or is the only valid pain relief opioids?
You are correct that anti-inflammatory drugs generally cannot be taken with Eliquis. This includes the commonly used class of anti-inflammatory drugs, the NSAIDs, many of which are available over the counter. Over the counter NSAIDs include:
Taking an NSAID with Eliquis, an anticoagulant (i.e. 'blood thinner') increases the risk of bleeding.
Even though NSAIDs are likely off the table if you take Eliquis, there are some potential alternatives available.
As stated above, taking NSAIDs with Eliquis can increase the risk of bleeding episodes.
The prescribing information for Eliquis states this explicitly:
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).
The prescribing information also states that a clinical study evaluating the combined use of aspirin (an NSAID) and Eliquis had to be stopped prematurely due to the increased risk of bleeding:
APPRAISE-2, a placebo-controlled clinical trial of apixaban [Eliquis] in high-risk, post-acute coronary syndrome patients treated with aspirin or the combination of aspirin and clopidogrel, was terminated early due to a higher rate of bleeding with apixaban compared to placebo.
Other studies that have evaluated the combined use of Eliquis with NSAIDs, like aspirin, have consistently reported a higher rate of bleeds versus those taking Eliquis alone.
Therefore, unless there are extenuating circumstances or other therapies aren't an option, NSAIDs shouldn't be used if you are taking Eliquis.
Since NSAIDs should generally not be used with Eliquis, this brings us to the question of what could be used instead. There are a few options to consider.
You mentioned Tylenol (acetaminophen) in your question, and you are correct that it is not considered an anti-inflammatory medication, but it should still be considered a potential option for some individuals.
To start, studies show that it is effective in the relief of both acute and chronic pain and is even preferred over NSAIDs in many cases since it carries, in general, fewer side effects (e.g. lower risk of bleeding and GI side effects).
Not only is Tylenol safer in many respects, but a variety of studies also show that it is just as effective as several NSAIDs for the treatment of several conditions, including osteoarthritis.
In fact, the American College of Rheumatology recommends it as first-line therapy (over NSAIDs) for osteoarthritis of the hip or knee.
Their guidelines cite a study published in the New England Journal of Medicine (NEJM) which found that 4 grams (4,000 milligrams) of acetaminophen per day was as effective as ibuprofen (in doses of 1.2-2.4 grams per day) for the short-term relief of joint pain and also improved overall physical function in those with osteoarthritis of the knee.
The study (from the NEJM) concluded:
In short-term, symptomatic treatment of osteoarthritis of the knee, the efficacy of acetaminophen was similar to that of ibuprofen, whether the latter was administered in an analgesic or an antiinflammatory dose.
So, Tylenol is certainly an option for the treatment of other conditions other than fever, even though it is not an 'anti-inflammatory'. Nevertheless, if Tylenol isn't an option for you or hasn't worked in the past, there are some other options.
We don't have a full understanding of whether or not it is safe to use topical NSAIDs, like Voltaren gel (diclofenac), in those taking blood thinners.
While the majority of their effects are local and based on the site of application (and not via absorption into the bloodstream), some of the drug does get absorbed, which could theoretically increase the risk of bleeding.
Most data suggests, however, that they are relatively safe.
We recently wrote an article regarding how much Voltaren gel is absorbed systemically (i.e. into the bloodstream) and discussed how studies show that a usual dose (4 grams of gel, applied four times per day) resulted in less than 6% of the total systemic exposure when compared to taking the same drug orally (at a dose of 150mg).
Unfortunately, there haven't been studies completed testing what effect this has (if any) on blood coagulation.
Nevertheless, a topical NSAID like Voltaren may be an option for you if you are exploring treatment options with your doctor. It would certainly be safer than taking an NSAID by mouth.
There are a variety of herbal products that may help to reduce inflammation and reduce pain associated with it.
However, there is an overall lack of data regarding the effectiveness and safety of many of these products.
The most commonly used herbal/natural remedies to treat pain and inflammation include:
- Arnica (topical)
- Devil's Claw
- Cat's Claw
- Fish Oil
Among these, fish oil, turmeric and Boswellia are perhaps the most well-studied.
Regarding Boswellia for example, one study concluded the following:
5-Loxin [an extract from boswellia] reduces pain and improves physical functioning significantly in OA [osteoarthritis] patients; and it is safe for human consumption. 5-Loxin may exert its beneficial effects by controlling inflammatory responses through reducing proinflammatory modulators, and it may improve joint health by reducing the enzymatic degradation of cartilage in OA patients.
Unfortunately, many of the herbal products listed above have also been reported to potentially 'thin' the blood and increase the risk of bleeding, especially on those taking anticoagulants.
Turmeric and fish oil are two examples which have been known to decrease coagulation and should be used cautiously in those who are more at risk for bleeding.
While some of these natural products may be options for you, you certainly want to discuss their use with your doctor before taking if you are also on Eliquis.
It can certainly be difficult to find a safe and effective pain medication, with anti-inflammatory properties, to take when also on an anticoagulant like Eliquis.
While NSAIDs generally shouldn't be used, there are other pain-relieving options available that your doctor could recommend, including Tylenol and topical analgesics.
There are also a variety of prescription medications available that your doctor may suggest that I haven't covered in this answer. Although none as classified as purely 'anti-inflammatory' drugs, medications like Cymbalta and tramadol have been used safely (although they may also thin the blood to a more mild degree).
Since there are many patient-specific factors to consider when choosing a pain/anti-inflammatory medication in those taking an anticoagulant, it is important to discuss potential treatment options with your doctor.
SummaryNSAIDs generally should not be taken with Eliquis due to the increased risk of bleeding events. Potential alternative therapies for the treatment of pain include Tylenol, topical NSAIDs and various herbal preparations.
- A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin for treatment of osteoarthritis of the knee. PubMed
- Eliquis Prescribing Information. BMS
- Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee. PubMed
- American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee
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