Major
Apixaban × Diclofenac
Direct oral anticoagulants (factor Xa inhibitors)×Non-steroidal anti-inflammatory drugs (NSAIDs)
Mechanism
Apixaban inhibits factor Xa; diclofenac injures the gastric mucosa and reduces platelet aggregation. Diclofenac additionally raises cardiovascular event risk, which matters in atrial fibrillation patients.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, blood in urine or stool, menorrhagia. Severe cases include gastrointestinal or intracranial haemorrhage. Risk rises in patients over 65 and with prior peptic ulcer disease.
Management
Avoid where possible. If diclofenac is needed for a short course, use the minimum effective dose for no more than 5–7 days under pantoprazole cover. For chronic analgesia, choose paracetamol, celecoxib, or topical NSAIDs.