Major
Diclofenac × Rivaroxaban
Non-steroidal anti-inflammatory drugs (NSAIDs)×Direct oral anticoagulants (factor Xa inhibitors)
Mechanism
Additive GI bleeding risk: anticoagulant (rivaroxaban) + ulcerogenic NSAID (diclofenac). Diclofenac additionally raises cardiovascular risk.
Symptoms
Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.
Management
Avoid prolonged combination. If diclofenac is needed for a short course, use the minimum effective dose for 5–7 days under pantoprazole cover. For chronic analgesia: paracetamol, celecoxib (less GI toxicity), or topical NSAIDs.