Anti-inflammatories and Eliquis

Hello all - I have been doing well Afib-wise, with no Afib for over 8 years and a Watchman implant last January, as I had a LAA done (by Dr. Natale). I continue on 2.5 mg of Eliquis twice/daily.

I've had Tendonitis behind my knee for a few weeks, and was prescribed Meloxicam, which is apparently a fairly strong anti-inflammatory. After 2 days on it, I noticed what looked like a purplish "pimple" on the top of one of my eyelids. It soon became more like a maroon blot and then a darker line basically outlining my eyelid. I stopped taking the Meloxicam because I was concerned it may have actually been a bleed over my eyelid.

Fast forward to today, when my knee still hurts (I was hoping it would just go away), so I called the pharmacist to ask if there might be a connection between the meds and Eliquis. She said "yes" and that I shouldn't take them together (the first pharmacist I called after this happened did not express much concern) I then drove over to my primary doctor's office who originally prescribed the Meloxicam, to show him the pictures I took (of my eye) and ask if it's OK or not to restart it again. He basically said "no" don't take it (didn't he notice I was on Eliquis when he originally prescribed this?) and to just take Tylenol (which we know is NOT an anti-inflammatory)..........Argh. SO...I called Dr. Natale and left a message, not realizing I had called his cell phone. He called me back within a few minutes and said it was OK to take myself off of Eliquis for a few days or even a week, and do the Meloxicam while off of it. As I am on a low dose and also have the Watchman, he was not concerned.

I have a number of thoughts/questions on all of this:

* Why does one pharmacist say it's not a big deal to take them together and the other one say it is? (same pharmacy, btw) I would like to believe that I can trust a pharmacist for medication advice/info.

* How could my own PCP not know this wasn't a good combo?

* If it's OK for me to get off of Eliquis so I can take this medication, do I really need to be on it still?

I am thankful I am on the lower dose, and also that I have the Watchman, so I have more flexibility when things like this come up.

Your comments are welcomed ~ Barb

First, if two pharmacists at the same institution are offering me contradictory advice or information, I would point out to them that they are in conflict and that one of them must be giving poorer advice, perhaps endangering their clients. This may sound confrontational, but the customer can only be right if he/she accepts one of the two forms of advice proffered. My well-being is important enough to me that I get them to sort it out, even in front of me if necessary. Or, I find another pharmacist, hoping I'm not going to succumb to confirmation bias.

Eliquis has a very mild residual effect over time. If you miss a single dose and follow instructions to wait to take the next one, you are not in any particular danger. But after that, you could be at some considerable risk for clotting unless you take something that is not contraindicated with what you must take or do.

Recently, my PCP prescribed Zopiclone to help me to get sleep about two weeks after my late-July ablation. When I went to fill it, having been advised to go easy on it and to stretch the whopping Rx for five whole pills out for a couple of weeks, the pharmacist immediately asked me if my PCP knew I had apnea. Yes, and I am well-treated, I replied. He insisted on calling my PCP who insisted that he fill the prescription. Leaning over the counter and talking past the back of his hand, the pharmacist advised me to use only half a tablet....but I ended up using only a quarter tab and got the relief I needed.

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tobherd
* Why does one pharmacist say it's not a big deal to take them together and the other one say it is? (same pharmacy, btw) I would like to believe that I can trust a pharmacist for medication advice/info.

* How could my own PCP not know this wasn't a good combo?

* If it's OK for me to get off of Eliquis so I can take this medication, do I really need to be on it still?

The answer to your first two questions is because it's beyond their realm of expertise. Pharmacist #1 probably thought it was no big deal because you were on a low dose of Eliquis, and pharmacist #2 knew better and disagreed. Likewise, your PCP probably isn't an expert in anticoagulant dosing and Watchman implants, so they didn't understand the nuances.

It sounds like you're like me -- you're taking low-dose Eliquis the same way many people take low-dose aspirin for general cardiovascular health, not because you need it acutely. So yeah, you're free to stop it for days or even weeks if needed. I was scheduled for hernia surgery just a few months after getting my Watchman, and the surgeon wanted me off Eliquis for 5 days. I asked Natale what to do, and his response was "Just stop like the surgeon wants." Eliquis is a long-term med for you now, not a daily med you really need. I have chosen to continue low-dose Eliquis indefinitely even though I have a Watchman and no afib for 5 years now. Just view it as your daily (more expensive but also safer and more effective) baby aspirin.

This happens... all.. the.. time.. for me. And I was discussing it recently with a friend whose all 3 kids have QT issues- her one EP wouldn't even commit to an answer as her daughter has an autoimmune disease and long QT and they were trying to figure out what drugs would be helpful for her.. When I was in the hospital to get on dofetilide, they had a pharmacist on my case to make sure there were no interactions. I wrote down her number and have called her quite a few times with supplement and drug interaction questions. I actually was looking up all my medications tonight and it was funny because there are "moderate interactions" for more than one combo. But I also know these are all Ok after discussions with doctors. But my GP and my regular pharmacist actually use the same app I do !!!! Like what's up with that?! LOL! Anyway if I have any questions I call the cardiac pharmacist. If your EP has one of those that is a great number to have. (Sounds like you got a hold of Natale though so that is even better.). I have also relied on the EP fellows (I will page them after hours as they are the ones that pick up those calls) or rarely my EP if I can actually get in touch with him but I don't even really trust the nurses and PAs in the EP dept.

To Gloaming - Dr. Natale told me it was fine to stay off of Eliquis for as long as I needed to, to go through the course of the medication I need to take for inflammation. I trust him implicitly, and since I have the Watchman implant, the risk of going off is not really an issue. The only reason i'm still on it as there seems to be no protocol for discontinuing Eliquis after a Watchman, when you've have an LAA ablation....and as an extra precaution for other clotting events unrelated to Afib.
I agree with you about the two pharmacists differing on their advice. I will have to point this out the next time something like this happens.

Yes, you are one of the reasons I decided to stay on low dose Eliquis, Carey. I was encouraged to by Dr. Natale and Shannon too, although it was my choice. I didn't realize I could just stop it if I needed to for things like avoiding medication interactions (such as I"m taking now), so that's good to have that flexibility.

Do any of you take Advil or Motrin when on Eliquis? I believe it's fine to take on low dose Eliquis, as long as it's not daily.....

With regard to medications, interactions, etc. I do think we need to ask good questions and make sure the right hand knows what the left hand is doing, so to speak. Be our own patient advocates, because we surely know, mistakes happen all the time.

I take Advil (Aleve is the brand I prefer) exceedingly seldom, about once a year...a single gel. This is only after overdoing something, chopping wood, walking hard and long (two-hours or more), raking all the leaves in one go...that type of thing. One gel seems to do the trick. I know not to take it often due to the gut-bleed risk with apixaban. I feel the risk is somewhat small for a single gel taken immediately after, or with, a substantial meal.

But, I guess my answer suggests it depends on your need for either drug. Could you go off apixaban for maybe three/four days to get you over a hump with Advil's help? I would do it. Would I begin to take Advil as part of a daily routine due to its salutary effects, even though I am taking even a low dose of apixaban? No, I would not. I would take Tylenol and hope to get a decent anti-inflammatory if I need Advil/ibuprofen for that property.

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gloaming
. I would take Tylenol and hope to get a decent anti-inflammatory if I need Advil/ibuprofen for that property.

I guess the question would be what decent anti-inflammatory similar to Aleve/ibuprofen could you get that would not conflict with eliquis—particularly if you needed to use it on a regular irregularl basis.

Define "regular irregular basis." Do you mean using an NSAID daily for a few days every now and then or do you mean using it daily for lengthy periods? The general rule is you can use NSAIDs with Eliquis daily for a few days, maybe a week, but that shouldn't be on a regular basis. There should be gaps between uses long enough to completely wash the NSAID out of your system and give your body a rest.

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gloaming
First, if two pharmacists at the same institution are offering me contradictory advice or information, I would point out to them that they are in conflict and that one of them must be giving poorer advice, perhaps endangering their clients. This may sound confrontational, but the customer can only be right if he/she accepts one of the two forms of advice proffered. My well-being is important enough to me that I get them to sort it out, even in front of me if necessary. Or, I find another pharmacist, hoping I'm not going to succumb to confirmation bias.

Eliquis has a very mild residual effect over time. If you miss a single dose and follow instructions to wait to take the next one, you are not in any particular danger. But after that, you could be at some considerable risk for clotting unless you take something that is not contraindicated with what you must take or do.

Recently, my PCP prescribed Zopiclone to help me to get sleep about two weeks after my late-July ablation. When I went to fill it, having been advised to go easy on it and to stretch the whopping Rx for five whole pills out for a couple of weeks, the pharmacist immediately asked me if my PCP knew I had apnea. Yes, and I am well-treated, I replied. He insisted on calling my PCP who insisted that he fill the prescription. Leaning over the counter and talking past the back of his hand, the pharmacist advised me to use only half a tablet....but I ended up using only a quarter tab and got the relief I needed.

Fantastic pharmacist.

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Carey
Define "regular irregular basis." Do you mean using an NSAID daily for a few days every now and then or do you mean using it daily for lengthy periods? The general rule is you can use NSAIDs with Eliquis daily for a few days, maybe a week, but that shouldn't be on a regular basis. There should be gaps between uses long enough to completely wash the NSAID out of your system and give your body a rest.

Before and after an ablation (total of three weeks) Natale and others put us on colchicine (very low dose) for its anti-inflammatory properties. It was formulated for gout, so this is off-label, but I can feel it working on general inflammation. This is not a drug that you are supposed to take continuously but perhaps you could ask about it as an option for short term relief. There are contraindications though but Eliquis is not one of them.

Dr Natale too had me use colchicine prior and post ablation 5 days ea. for reducing risk of peracarditis since i had it post ablation 6 months earlier here in charlotte
I was also given lasix in my iv morning after ablation. No peracarditis

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Mark
. I would take Tylenol and hope to get a decent anti-inflammatory if I need Advil/ibuprofen for that property.

I guess the question would be what decent anti-inflammatory similar to Aleve/ibuprofen could you get that would not conflict with eliquis—particularly if you needed to use it on a regular irregularl basis.

[www.ncbi.nlm.nih.gov]

It seems good 'ol naproxen is okay, although it does have a way of inflating the bioavailability of apixaban in the intestines, if I read correctly:

"...Co-administration with less potent CYP3A4 or P-gp inhibitors resulted in a more modest effect on apixaban exposure. Following administration with naproxen, a P-gp inhibitor with no activity toward CYP3A4 or BCRP, at an intestinal concentration of 6–10 mM [26], apixaban Cmax and AUC0–∞ were 61% and 54% higher, respectively, than values following administration of apixaban alone [59]. Similarly, following co-administration with diltiazem, a moderate inhibitor of CYP3A4 and a weak inhibitor of P-gp, apixaban Cmax and AUC0–∞ were 31% and 40% higher, respectively, than values observed following administration of apixaban alone [58]. Clarithromycin, an inhibitor of P-gp and a strong inhibitor of CYP3A4, led to a 1.3- and 1.6-fold increase in mean apixaban Cmax and AUC0–∞, respectively [3]. No dose adjustment of apixaban is required when administered with agents that are not considered strong inhibitors of both CYP3A4 and P-gp, such as naproxen, diltiazem, and clarithromycin [3, 4]..."

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Carey
Define "regular irregular basis." Do you mean using an NSAID daily for a few days every now and then or do you mean using it daily for lengthy periods? The general rule is you can use NSAIDs with Eliquis daily for a few days, maybe a week, but that shouldn't be on a regular basis. There should be gaps between uses long enough to completely wash the NSAID out of your system and give your body a rest.

For me, “regular irregular” means about two Aleve tabs per week and probably a few more tabs than that if it were ibuprofen. They help treat an arthritic condition and really do make a difference. Tylenol not so much. Some discussion about a watchman with the EP which perhaps could negate taking the eliquis. However, my age and health history would likely still result in docs continuing to recommend at least a low dose of eliquis. Was just hoping someone found something new out there that was more eliquis user friendly. But good info here.

I doubt that 2-3 tabs per week of any NSAID is going to be a problem with Eliquis. It's daily use that creates an issue.

Carey - can you answer my question about why Dr. Natale would tell me to go back on Eliquis after my anti-inflammatory protocol is over? If it's safe enough to be off of it for a week, why is is needed at all?

I still am aggravated by the fact that I"m still on a blood thinner even after getting the Watchman.... Barb

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tobherd
Carey - can you answer my question about why Dr. Natale would tell me to go back on Eliquis after my anti-inflammatory protocol is over? If it's safe enough to be off of it for a week, why is is needed at all?

I still am aggravated by the fact that I"m still on a blood thinner even after getting the Watchman.... Barb

I can't speak for him, obviously, but I would imagine there are two reasons. The first is simply an abundance of caution. The official FDA protocol calls for aspirin for life, but he knows that Eliquis is safer and more effective than aspirin. The reason the FDA has that protocol is there's no way to verify that the device has been completely endothelialized short of open heart surgery, so in the unlikely event that happens you would have bare metal exposed to the blood flow, and that could attract clots. I think it's more of an imaginary risk because European doctors don't follow that protocol and I've never heard of a device-related thrombus after the six week point.

The second reason is the same reason doctors have been prescribing low-dose aspirin for older adults for many years. The LAA isn't the only place in your body that clots can form, and you almost certainly have at least some arterial plaque (virtually everyone over 60 does). Plaque can rupture and clots can then form on the rupture. So the Eliquis will protect you from that.

Why do you need it at all if it's safe to stop for a week? That's pure probabilities math. The longer you remain off the Eliquis, the more time there is for bad things to happen.

Now, some people don't find these reasons compelling so they simply stop taking it. You can do that. It's entirely your choice. I made the decision to continue the 1/2 dose Eliquis because I don't fear it in the least, it has no side effects for me, and I spent 15 years seeing what strokes do to people. Death is not the worst outcome at all. It gets much worse than that, so I would much prefer a little caution over being a bed-ridden, incontinent houseplant who can't swallow or talk so has to wear a bib to catch the drool.

Besides, now I can take that 18-hour flight to New Zealand without worrying about DVTs.

Couple of things on what you wrote, Carey. I certainly understand your perspective given all you've witnessed as an EMT. I do wonder then if everyone over age 60 or so, should then be on Eliquis, if it's risky to not be on it.....

.I recently had a cardiac Cat Scan and was told my results were excellent. NO blockages, minimal plaque and minimal calcium...my Cardiologist was very pleased. Interestingly, I tend to have high total cholesterol and high LDL (but also high HDL and low triglycerides)...so my body seems to handle the cholesterol well, according to these test results. I take a lot of high quality supplements, including Omega 3's and vitamin E, as well as an excellent cardiac supplement that was developed with the help of Dr. John Folts (who brought us the "aspirin a day" therapy). I also exercise regularly. A pulmunologist I saw. today expressed surprise that I was still on a blood thinner after getting the Watchman, and said the main reasons someone gets a stroke is Afib (which I no longer have), high BP (mine is controlled well with meds), and I believe he said blood clots. He's sending me for a sonogram of my legs (to make sure there are no clots....no indication there are, but I've been short of breath for over 6 years and I wanted him to do some testing). Assuming there are no clots, and given my good Cardiac Cat Scan, and the fact that I haven't had Afib in over 8 years and have a Watchman, am I really much of a risk of having a stroke?

I know you're not a doctor and I don't mean to come back at you, Carey....just venting and questioning all at the same time. If I'm becoming redundant and annoying, just scroll by......~ Barb

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tobherd
Assuming there are no clots, and given my good Cardiac Cat Scan, and the fact that I haven't had Afib in over 8 years and have a Watchman, am I really much of a risk of having a stroke?

No, probably not. It would be entirely reasonable for you to stop taking an anticoagulant if that's what you want to do.

I've tried to convey that it was a personal decision for me that others might not choose for themselves, and that's okay. We're dealing with probabilities here and the numbers are often quite small. I simply fear stroke far more than I fear anticoagulants. Your fears may differ.