Combining different supplements and medications can be complex, especially when it comes to maintaining both efficacy and safety. Eliquis (apixaban) is a commonly prescribed anticoagulant used to prevent blood clots and reduce the risk of stroke. Probiotics, on the other hand, are live microorganisms that provide health benefits when consumed in adequate amounts. They can help modulate the gut microbiota, enhancing its overall composition and function.

As more people turn to probiotics for their health benefits, a common question arises: Can I take probiotics with Eliquis? This article explores the safety tips and recommendations for those considering adding probiotics to their regimen while on Eliquis therapy. We will discuss potential interactions and the importance of consulting healthcare providers to ensure a safe and effective combination.

Key Findings

  • The interaction between gut microbiota and direct oral anticoagulants like Eliquis is not fully understood, but changes in gut bacteria can impact drug metabolism and effectiveness.
  • The gut microbiota significantly influences various physiological processes, including the metabolism of drugs like Eliquis, which relies on intestinal transporter P-glycoprotein (P-gp) and cytochrome P450 (CYP) enzymes.
  • Oral anticoagulants (OACs) can alter gut microbiota, potentially increasing beneficial bacteria like Bifidobacterium and Lactobacillus while reducing harmful bacteria levels.
  • Be vigilant for signs of bleeding, such as prolonged bleeding from cuts, frequent nosebleeds, blood in urine or stools, and unexplained bruising, which can indicate that Eliquis is working too strongly.
  • There is no one-size-fits-all dosage for probiotics. Start with a lower dose and gradually increase it, observing how your body responds. Consistency is key for maximum benefits.
  • Certain groups, such as immunocompromised individuals, people with severe illnesses, and those with allergies to probiotic components, should be particularly cautious when considering probiotics.
  • There are currently no studies directly assessing the safety and efficacy of taking probiotics while on Eliquis therapy.

Potential Interactions of Eliquis and Probiotics

The interaction between the gut microbiota and direct oral anticoagulants like apixaban (Eliquis) is an area of growing interest, although not yet fully understood. A study found that vitamin K synthesis decreases when antibiotics reduce the gut bacterial population, enhancing the anticoagulant effect of vitamin K antagonists like warfarin. This example highlights how gut microbiota can impact drug metabolism and effectiveness, a concept that might extend to direct oral anticoagulants like apixaban (Eliquis).

The Gut Microbiota and Eliquis’ Metabolism

A split view of red blood cells on one side and gut microbiota on the other.

Safety Tips for Using Probiotics with Eliquis

The gut microbiota, a complex ecosystem of microorganisms residing in the human body, significantly influences various physiological processes, including immune function, nutrition, metabolism, and pharmacological reactions. These microorganisms, particularly those in the gastrointestinal tract, play essential roles in the metabolism and safety of many drugs, including apixaban (Eliquis).

Apixaban relies on the intestinal transporter P-glycoprotein (P-gp) and the cytochrome P450 (CYP) enzymes for its metabolism and elimination. These proteins are vital in the gut, where they work together to regulate how much of a drug is absorbed and how much is broken down and eliminated. Specifically:

  • P-glycoprotein: P-gp acts like a pump, moving substances, including drugs, out of the cells and into the intestinal tract. By expelling drugs back into the intestines, P-gp can reduce the amount of drug absorbed into the bloodstream, thereby affecting drug absorption.
  • Cytochrome P450 enzymes: CYP enzymes CYP3A4, CYP1A2, CYP2J2, CYP2C8, CYP2C9, and CYP2C19 help break down apixaban. They are highly present in the lining of the small intestine and metabolize drugs, meaning they chemically alter them to help the body use and eliminate them. By breaking down drugs, CYP enzymes help control the amount of apixaban that stays active in the body.

The gut microbiota can influence the activity of these proteins. For example, changes in the gut microbiota composition might alter the expression or function of P-gp and CYP3A4, impacting how apixaban is metabolized and eliminated.

Effects of Oral Anticoagulants on the Gut Microbiota

A recent study found notable differences in gut bacteria in patients with atrial fibrillation (AF) taking oral anticoagulants (OACs) and those not taking them. AF patients had lower levels of beneficial bacteria, such as Bifidobacterium and Lactobacillus (commonly considered a group of probiotics), compared to the control group. However, patients on OACs showed an increase in these beneficial bacteria.

Additionally, OACs reduced the levels of Ruminococcus, a bacteria associated with inflammation, but simultaneously increased the levels of potentially harmful bacteria, including Streptococcus, Escherichia-Shigella, and Klebsiella.

In another study, researchers used antibiotic-treated rats to create a model of gut dysbiosis (an imbalance in the gut microbiota) to study how this imbalance affects the pharmacokinetics of rivaroxaban, a Factor Xa inhibitor like apixaban. Antibiotics are known to disrupt the balance of gut microbiota by killing off harmful and beneficial bacteria.

Here are the key findings of the study:

  • There was a slight increase in rivaroxaban’s bioavailability in the antibiotic-treated groups compared to the control. This means that a greater amount of rivaroxaban is entering the bloodstream, potentially making it more effective at preventing blood clots.
  • The clearance rate decreased, and the elimination half-life increased significantly in the antibiotic-treated groups, indicating that rivaroxaban is being removed from the body more slowly.
  • The Time to Peak Concentration (Tmax/h) decreased in the antibiotic-treated groups, showing that rivaroxaban reached its maximum concentration faster.

While the anticoagulant effect of rivaroxaban might be enhanced under conditions of gut dysbiosis, this also raises the risk of adverse effects, particularly bleeding complications. The overall safety profile necessitates careful monitoring and potentially adjusting the dosage to balance efficacy and safety.

Further research is ongoing to fully understand these interactions and how they can be leveraged for personalized medicine.

Safety Tips for Using Probiotics with Eliquis

A person holding two white capsules in their open palm, with a glass of water in the other hand.

Here are some safety tips for taking probiotics while using Eliquis to ensure you manage your health effectively:

1. Consult with Healthcare Providers

Ask specifically about the potential interactions between Eliquis and the type of probiotics you plan to take. Understand that not all probiotics are the same. Different strains of probiotics can have different effects on your gut flora and, consequently, on how your body processes Eliquis. Bring a list of the probiotic products you are considering, including their specific strains, to get tailored advice.

2. Regular Blood Testing

When taking Eliquis, regular blood testing is not as frequently required as with other anticoagulants like warfarin. However, blood tests can help detect any changes in how Eliquis is working in your body. Regular monitoring helps ensure that your medication levels remain therapeutic without causing an increased risk of bleeding or clotting.

3. Watch for Signs of Bleeding

Knowing the specific signs of excessive bleeding (such as prolonged bleeding from minor cuts, unusual bruising, or blood in urine/stools) can help you act quickly. Keep a journal of any symptoms you notice after starting probiotics to discuss with your doctor. Here are the key signs of bleeding to watch for:

External Bleeding

  • Prolonged Bleeding from Cuts: Notice if small cuts or injuries bleed longer than usual or are difficult to stop.
  • Frequent Nosebleeds: Recurring or prolonged nosebleeds without a clear cause can indicate a bleeding issue.
  • Bleeding Gums: Gums that bleed easily, especially during brushing or flossing, may be a sign of a bleeding problem.

Internal Bleeding

  • Blood in Urine: Pink, red, or brown-colored urine can be a sign of bleeding in the urinary tract.
  • Blood in Stools: Look for bright red blood, black, tarry stools, or maroon-colored stools, which can indicate gastrointestinal bleeding.
  • Heavy Menstrual Bleeding: Women may experience unusually heavy or prolonged menstrual periods.


  • Unexplained Bruises: Large, painful bruises that appear without any apparent injury.
  • Bruises that Increase in Size: Watch for bruises that continue to spread or get larger over time.

Other Symptoms

  • Coughing up Blood: Blood in the mucus or saliva when coughing can indicate bleeding in the respiratory tract.
  • Severe Headache or Dizziness: Persistent or severe headaches, dizziness, or weakness may be a sign of internal bleeding, particularly in the brain.
  • Unusual Tiredness or Weakness: Unexplained fatigue or weakness can result from blood loss.
  • Joint Pain or Swelling: Painful, swollen joints without obvious injury could indicate bleeding into the joints.

When to Seek Immediate Medical Attention

  • Sudden, Severe Headache: Especially if it is the worst headache you’ve ever experienced, it could indicate a brain hemorrhage.
  • Vomiting Blood: Vomit that looks like coffee grounds can be a sign of upper gastrointestinal bleeding.
  • Severe Abdominal Pain: Severe, persistent abdominal pain may indicate internal bleeding.
  • Shortness of Breath or Chest Pain: These symptoms, along with bleeding signs, require immediate medical evaluation.

Contact your healthcare provider immediately if you experience any unusual symptoms or if you have concerns about bleeding.

4. Dosage Recommendations

There is no one-size-fits-all dosage for probiotics. Recommendations vary based on the specific strain and the individual’s health needs. It is advisable to start with a lower dose and gradually increase it, observing how the body responds. To minimize potential interactions, consider:

  • Taking probiotics at a different time of day than Eliquis.
  • Ensuring consistent daily intake for maximum benefits.
  • Choosing high-quality probiotic supplements with well-documented strains.

Consistency helps maintain a stable gut environment, minimizing the risk of fluctuations in medication efficacy. Abrupt changes in your probiotic routine can lead to unexpected interactions.

5. Choose Probiotics Wisely

Seek advice on which strains of probiotics are known to be safer for individuals on anticoagulants. Ask about specific brands or formulations that have been studied for their interactions with blood thinners. Doing thorough research or consulting a nutritionist can help you select a probiotic that complements your health regimen without compromising your anticoagulant therapy. Examples of probiotic strains that are generally considered safe and beneficial include:

  • Lactobacillus rhamnosus gg
  • Bifidobacterium lactis
  • Lactobacillus acidophilus
  • Lactobacillus plantarum
  • Bifidobacterium longum
  • Saccharomyces boulardii

Dietary Sources of Probiotics

An assortment of fermented foods, including a glass of kombucha, pickled onions, kimchi, and sauerkraut.

Consuming dietary sources of probiotics can be a safe and effective way to support gut health while on Eliquis (apixaban) therapy. Here are some natural, food-based probiotics that are generally considered safe:

  • Yogurt: A well-known probiotic-rich food made from fermented milk. It contains live cultures such as Lactobacillus and Bifidobacterium. Choose plain, unsweetened yogurt to avoid added sugars and artificial ingredients. Look for labels that mention “live and active cultures” for the best probiotic benefits.
  • Kefir: A fermented milk drink similar to yogurt but with a more diverse range of probiotic strains. It can be made from cow, goat, or sheep milk. Kefir, made from water or coconut milk, is available for those with lactose intolerance.
  • Sauerkraut: A fermented cabbage rich in probiotics and vitamins. Store-bought sauerkraut often contains preservatives, so homemade or naturally fermented versions are preferable.
  • Kimchi: A spicy Korean fermented vegetable dish, typically made from cabbage and radishes. It contains Lactobacillus and other lactic acid bacteria. Be cautious of high sodium levels if you have dietary restrictions.
  • Miso: A traditional Japanese paste made from fermented soybeans. It contains beneficial bacteria like Tetragenococcus halophilus. You can add miso to dishes like soups at the end of cooking to preserve the probiotics, as excessive heat can kill beneficial bacteria.
  • Tempeh: Tempeh is a fermented soybean product that is a good source of probiotics and protein. Incorporate tempeh into your diet by steaming, sautéing, or adding it to salads and stir-fries.
  • Pickles: Ensure the pickles are naturally fermented with brine (saltwater) and not made with vinegar, as vinegar-based pickles do not contain probiotics.
  • Kombucha: Kombucha is a fermented tea beverage rich in probiotics and antioxidants. Choose kombucha with low sugar content and monitor your intake, as excessive consumption can lead to digestive upset.

It is essential to consult a professional to determine the appropriate amount of these probiotic-rich foods. The recommended consumption can vary significantly from person to person, depending on individual health conditions, dietary requirements, and potential interactions with Eliquis.

Risks and Considerations of Taking Probiotics with Eliquis

When combining probiotics with Eliquis, it’s essential to be aware of the potential risks and considerations to ensure safe and effective use.

Potential Side Effects of Probiotics 

While probiotics are generally considered safe for most people, they can cause side effects, particularly when first introduced to the diet. Here are some potential side effects to be mindful of:

1. Gastrointestinal Issues

The introduction of new bacteria to the gut can lead to an increase in gas production, causing bloating and discomfort. Some individuals may also experience diarrhea as their digestive system adapts to the new probiotic strains. Additionally, mild abdominal pain or cramps may occur, particularly in individuals with sensitive digestive systems. These side effects are typically temporary as the body adjusts.

2. Allergic Reactions

Although rare, some people might experience allergic reactions to specific probiotic strains, manifesting as itching, rash, or mild swelling. Symptoms of a severe allergic reaction might include difficulty breathing, severe swelling, or anaphylaxis. Immediate medical attention is required in such cases.

3. Infection Risk

People with weakened immune systems, such as those undergoing chemotherapy, taking immunosuppressive drugs, or living with HIV/AIDS, may be at a higher risk of developing infections from probiotic bacteria.

Special Populations: Who Should Be Cautious?

Certain populations should exercise extra caution when considering probiotics while taking Eliquis due to the potential for increased risks and complications:

1. Immunocompromised Individuals

As mentioned, those with compromised immune systems are more susceptible to infections. Introducing live bacteria through probiotics could pose a significant health risk. Consultation with a healthcare provider is essential before starting probiotics.

2. Individuals with Severe Illnesses

People with critical illnesses or those in intensive care units should avoid probiotics unless advised by their healthcare team, as their bodies may not effectively handle an additional bacterial load.

3. Patients with Short Bowel Syndrome

Individuals with short bowel syndrome or other conditions that result in reduced gut length are at a higher risk of bacterial overgrowth. Probiotics can exacerbate this condition, leading to complications.

4. Those with Allergies to Probiotic Components

People with known allergies to specific components in probiotic supplements should avoid these products to prevent allergic reactions. Common allergens that may be present in probiotic supplements include dairy, gluten, soy, yeast, corn, artificial colors and flavors, and preservatives. Reading labels and consulting healthcare providers can help identify safe options.

Understanding the potential side effects and identifying special populations who should be cautious can help mitigate the risks associated with taking probiotics alongside Eliquis.


While there aren’t any significant interactions between probiotics and Eliquis, it is important to consider potential impacts on anticoagulation. Studies have shown that a reduced gut bacterial population and an imbalance in the gut microbiota can enhance the anticoagulation effects of warfarin and rivaroxaban. Taking probiotics, which increases the gut bacterial population, might provide the opposite effect, potentially decreasing the bioavailability of apixaban (Eliquis).

Additionally, it’s also found that oral anticoagulants and the gut microbiota have bidirectional effects where oral anticoagulants can increase or decrease certain bacteria. This interaction further complicates the relationship between gut health and anticoagulant therapy.

However, there are no studies directly assessing the safety and efficacy of taking probiotics while on Eliquis therapy. Therefore, always consult your healthcare provider before starting probiotics to ensure they are safe and appropriate for your specific health needs and medication regimen. By doing so, you can make informed decisions and safely incorporate probiotics into your health routine.

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Frequently Asked Questions

What can you not take with Eliquis?

It is important to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin, as these can enhance the risk of bleeding. Other medications to avoid include other anticoagulants, such as warfarin and heparin, unless specifically instructed by a healthcare provider. Additionally, grapefruit and grapefruit juice should be avoided because they can affect how Eliquis is metabolized in the body, potentially leading to increased levels of the drug and a higher risk of bleeding.

What antibiotics interact with Eliquis?

Several antibiotics can interact with Eliquis by affecting its metabolism and potentially altering its effectiveness. Antibiotics like clarithromycin, erythromycin, and rifampin are known to either increase or decrease the levels of Eliquis in the blood. Clarithromycin and erythromycin can increase the concentration of Eliquis, heightening the risk of bleeding. Conversely, rifampin can decrease Eliquis levels, reducing its efficacy and increasing the risk of clot formation.

What supplements interfere with Eliquis?

Certain supplements can interfere with the effectiveness of Eliquis or increase the risk of side effects. St. John’s Wort, a common herbal supplement used for depression, can reduce the effectiveness of Eliquis by increasing its breakdown in the liver. Fish oil and omega-3 fatty acids, commonly taken for heart health, can have a mild blood-thinning effect, which might increase the risk of bleeding when taken with Eliquis. Additionally, high doses of vitamin E can also have anticoagulant effects and should be used cautiously.

What supplements can I take with Eliquis?

While certain supplements should be avoided with Eliquis, others can be taken safely, often under the guidance of a healthcare provider. For instance, calcium and vitamin D supplements are generally safe and do not interact with Eliquis. Probiotics and multivitamins, when taken at recommended doses, are also typically safe. However, it’s important to ensure that multivitamins do not contain high doses of vitamin E or other substances that can affect blood clotting.

How often should Eliquis be taken?

Eliquis is usually taken twice a day, about 12 hours apart, to maintain a consistent level of the medication in your bloodstream. It is important to take Eliquis at the same times every day to ensure its effectiveness in preventing blood clots. If you miss a dose, take it as soon as you remember on the same day, and then continue with your regular dosing schedule. Do not take two doses at once to make up for a missed dose. Adhering to the prescribed schedule is crucial for managing your condition effectively.

What herbs interact with Eliquis?

Several herbs can interact with Eliquis, either by enhancing its anticoagulant effects or by affecting its metabolism. St. John’s Wort can decrease the effectiveness of Eliquis by speeding up its breakdown in the liver. Ginkgo biloba, used for cognitive health, can increase the risk of bleeding due to its blood-thinning properties. Garlic supplements, especially in high doses, can also enhance bleeding risk. Additionally, turmeric and ginger, which have mild anticoagulant effects, should be used cautiously.

Are there specific probiotic strains to avoid when taking Eliquis?

Certain probiotic strains might be riskier when used alongside medications. It is best to avoid soil-based organisms (SBOs) and instead opt for well-researched strains such as Lactobacillus GG and Saccharomyces boulardii. If you’re uncertain about a particular probiotic, consult your pharmacist for advice.

Are there specific timing guidelines for taking probiotics with Eliquis?

It is advisable to take your Eliquis dose with food and wait at least two hours before consuming your probiotic supplement. This helps to prevent the probiotic from affecting the absorption of Eliquis from your gut. You might find it helpful to set a reminder to ensure the doses are appropriately spaced.

What actions should I take if I experience side effects while taking probiotics and Eliquis?

If you experience side effects like increased bleeding, bruising, rash, severe digestive issues, or other concerning symptoms after starting probiotics, contact your doctor immediately. Your healthcare provider can determine whether it is safe to continue the probiotic and may need to adjust your Eliquis dosage or other medications.

Is it safe to take a yeast-based probiotic like Saccharomyces boulardii with Eliquis?

Saccharomyces probiotics are generally considered safe to take with Eliquis, but you should check with your doctor first. These probiotics may not be suitable if you have a yeast allergy, a central venous catheter, or other specific medical conditions. As a precaution, take yeast probiotics at least two hours apart from your Eliquis dose.



Sánchez-Fuentes, A., Rivera-Caravaca, J. M., López-Gálvez, R., Marín, F., & Roldán, V. (2022). Non-vitamin K Antagonist Oral Anticoagulants and Drug-Food Interactions: Implications for Clinical Practice and Potential Role of Probiotics and Prebiotics. Frontiers in cardiovascular medicine, 8, 787235.

Li, W., Li, C., Ren, C., Zhou, S., Cheng, H., Chen, Y., Han, X., Zhong, Y., Zhou, L., Xie, D., Liu, H., & Xie, J. (2023). Bidirectional effects of oral anticoagulants on gut microbiota in patients with atrial fibrillation. Frontiers in Cellular and Infection Microbiology, 13.

Chen, W., Qian, J., Fu, J., Wu, T., Lv, M., Jiang, S., & Zhang, J. (2022). Changes in the gut microbiota may affect the clinical efficacy of oral anticoagulants. Frontiers in Pharmacology, 13.