Major
Apixaban × Ketorolac
Direct oral anticoagulants (factor Xa inhibitors)×Non-steroidal anti-inflammatory drugs (NSAIDs)
Mechanism
Apixaban inhibits factor Xa, while ketorolac is the most potent available NSAID. Ketorolac injures the gastric mucosa and inhibits platelet aggregation. Massive GI bleeding risk increases several-fold. FDA Toradol Section 4.3 lists anticoagulants as contraindications.
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
The combination is not prescribed. For analgesia in a patient on apixaban, use paracetamol (up to 3 g/day), metamizole, or a short opioid course. Ketorolac courses never exceed 5 days under any circumstances.