Eliquis (apixaban) is a blood thinner that reduces your body’s ability to form clots, which means anything that further increases bleeding risk or interferes with how the drug works in your body deserves attention. The list of things to avoid or limit spans pain medications, certain prescriptions, herbal supplements, alcohol, and specific physical activities.
NSAIDs and Pain Relievers
This is the most common pitfall. Over-the-counter anti-inflammatory drugs like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin all increase bleeding risk on their own. Combining them with Eliquis compounds the problem significantly. Data from the ARISTOTLE trial found that people on oral anticoagulants who started taking NSAIDs had a 61% higher risk of major bleeding compared to those who didn’t.
Diclofenac and ibuprofen were the most commonly used NSAIDs among trial participants, but the risk applies across the entire class. If you need pain relief while on Eliquis, acetaminophen (Tylenol) is generally the safer option. That said, high doses of acetaminophen carry a risk of liver damage, so stick to the lowest effective dose and don’t take it longer than necessary. For chronic joint pain, physical therapy to strengthen the muscles around the affected joint can reduce the need for painkillers altogether.
Prescription Drugs That Change Eliquis Levels
Eliquis is processed in your body through two specific pathways. Certain medications can either block those pathways (causing Eliquis to build up to dangerously high levels) or speed them up (flushing Eliquis out before it can work).
Drugs that increase Eliquis levels in your blood include the antifungals ketoconazole and itraconazole, the antibiotic clarithromycin, and the HIV medication ritonavir. When these are prescribed alongside Eliquis, your dose typically needs to be cut in half. If you’re already on the lower 2.5 mg twice-daily dose, these combinations should be avoided entirely because there’s no safe way to reduce the dose further.
On the other end, certain drugs pull Eliquis out of your system too quickly, leaving you without adequate protection against blood clots. The FDA’s prescribing information specifically warns against combining Eliquis with rifampin (an antibiotic used for tuberculosis), carbamazepine and phenytoin (seizure medications), and St. John’s wort. If you’re prescribed any new medication while taking Eliquis, your pharmacist can flag interactions at the counter, but it’s worth asking proactively.
Herbal Supplements and Natural Products
St. John’s wort is the most dangerous herbal supplement to take with Eliquis. It activates the same pathways that break down the drug, potentially reducing its effectiveness enough to leave you vulnerable to a stroke or clot. The FDA lists it alongside prescription drugs as something to avoid.
Beyond St. John’s wort, several common supplements either slow the breakdown of Eliquis or have their own mild blood-thinning properties. These include garlic, echinacea, valerian, green tea extract, ginkgo biloba, ginger, ginseng, and horse chestnut. None of these carry the same level of risk as St. John’s wort, but layering multiple supplements with even modest effects on bleeding or drug metabolism can add up. If you take any of these regularly, bring the full list to your prescriber.
Alcohol
Moderate alcohol consumption is not off-limits, but it does need boundaries. The National Blood Clot Alliance recommends limiting intake to no more than two drinks in a single sitting, with one drink defined as one beer, one glass of wine, one cocktail, or one shot of liquor. Heavy or binge drinking raises bleeding risk, impairs your liver’s ability to produce clotting factors, and increases the chance of falls and injuries where uncontrolled bleeding becomes a real concern.
High-Impact Sports and Risky Activities
Because Eliquis reduces your ability to stop bleeding, injuries that would normally be minor can become more serious. Current guidelines from the American College of Cardiology recommend that people on anticoagulants avoid high-impact competitive sports, including football, ice hockey, soccer, basketball, and lacrosse.
The risk isn’t limited to contact sports. Activities like cycling, skiing, climbing, and surfing carry their own dangers, primarily from falls and potential head injuries. A head injury on a blood thinner can lead to internal bleeding that’s harder to control and slower to detect. That doesn’t mean you need to stop all physical activity. Exercise is important, and the decision about which activities to continue is ultimately a personal one made with your doctor, factoring in your specific health situation and how much risk you’re comfortable accepting.
Timing Around Surgery and Dental Work
You’ll need to pause Eliquis before most procedures, but the timeline depends on how much bleeding the procedure involves. Current perioperative guidelines from the American College of Cardiology break it down into tiers:
- Minimal bleeding risk (dental extractions, skin lesion removal): skip one dose, either the morning of or the evening before the procedure.
- Low-to-moderate bleeding risk (gallbladder removal, hernia repair): stop Eliquis one day before the procedure, roughly 30 to 36 hours ahead.
- Higher bleeding risk (major joint replacement, cancer surgery): stop two days before, roughly 60 to 68 hours ahead.
- Spinal or epidural anesthesia: stop three days before the procedure.
Never stop Eliquis on your own before a procedure. Your surgical or dental team will coordinate the timing with whoever prescribed your blood thinner to make sure you’re protected from clots while minimizing bleeding risk during the procedure itself.
Pregnancy and Breastfeeding
Eliquis is not recommended during pregnancy. The limited data available isn’t enough to rule out risks to fetal development, and taking any anticoagulant during pregnancy increases the risk of bleeding during delivery for both the mother and the baby. Spinal or epidural anesthesia during labor while on Eliquis can also lead to dangerous blood collections near the spine. If you’re of reproductive age and need long-term anticoagulation, pregnancy planning should be part of the conversation with your prescriber so you can transition to a safer alternative before conceiving.
Breastfeeding is also not recommended while on Eliquis. There’s no human data on whether the drug passes into breast milk, but animal studies found it present in rat milk, which was enough for the manufacturer to advise against nursing during treatment.