OBJECT DRUGS

Anticoagulants, Oral:

• Acenocoumarol
• Phenprocoumon
• Warfarin (Coumadin, etc.)

PRECIPITANT DRUGS

NSAIDs:

• Diclofenac (Voltaren, etc.)
• Diflunisal (Dolobid)
• Etodolac (Lodine)
• Fenoprofen (Nalfon)
• Flurbiprofen (Ansaid, etc.)
• Ibuprofen (Motrin, etc.)
• Indomethacin (Indocin, etc.)
• Ketoprofen (Orudis)
• Ketorolac (Toradol, etc.)
• Meclofenamate
• Mefenamic acid
• Meloxicam (Mobic)
• Nabumetone (Relafen)
• Naproxen (Aleve, etc.)
• Oxaprozin (Daypro)
• Piroxicam (Feldene)
• Sulindac (Clinoril)
• Tolmetin (Tolectin)

Comment:

All NSAIDs reversibly inhibit platelet function and cause gastric erosions. The risk of GI bleeding appears to be considerably increased with NSAIDs plus warfarin compared to either drug used alone. Some NSAIDs can increase the hypoprothrombinemic response to oral anticoagulants.

Class 2: Use Only if Benefit Felt to Outweigh Risk

• Use Alternative: Use a non-NSAID analgesic if possible such as acetaminophen (see Acetaminophen discussion under Anticoagulants, Oral + Aspirin). If a NSAID is required, non-acetylated salicylates such as choline magnesium trisalicylate (Trilisate), magnesium salicylates, and salsalate (Disalcid) are probably safer due to minimal effects on platelets and gastric mucosa; if large doses are used, monitor INR. COX-2 inhibitors produce no platelet inhibition and probably less gastric damage. Studies indicate that celecoxib does not affect warfarin response. However, isolated case reports of warfarin interactions with celecoxib have appeared, and epidemiologic evidence suggests that COX-2 inhibitors may increase the risk of upper GI hemorrhage in patients on warfarin. If a standard NSAID is used, consider using NSAIDs that are unlikely to affect the hypoprothrombinemic response such as diclofenac, ibuprofen, naproxen, and tolmetin.
• Monitor: If any NSAID is used with an oral anticoagulant, monitor carefully for evidence of bleeding, especially from the GI tract.