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Nonsteroidal anti-inflammatory drugs (standard or coxibs) - prescribing issues - Management
What should I do for a person who requires warfarin and an NSAID?

  • All nonsteroidal anti-inflammatory drugs (NSAIDs) can cause gastrointestinal irritation and reduce platelet aggregation, which can worsen any bleeding event. All NSAIDs can also increase the international normalized ratio (INR). The magnitude of the increase in INR varies in different reports.
  • If a person receiving warfarin requires an NSAID:
    • Consider referral to, or consultation with, a specialist.
    • Do not use azapropazone, ketorolac, or phenylbutazone. The risk of serious bleeding is greater with these drugs than with other NSAIDs.
    • For all other NSAIDs, consider whether an NSAID is necessary:
      • If an NSAID is considered necessary, prescribe gastroprotection (e.g. a coxib and a proton pump inhibitor) and closely monitor the INR when initiating the NSAID, changing its dose, or discontinuing it.
      • If the INR increases, reduce the warfarin dose as appropriate.
  • Reports of NSAID interactions with anticoagulants other than warfarin are limited, but other anticoagulants would be expected to have interactions with NSAIDs similar to those of warfarin.
Basis for recommendation
  • These recommendations are based on information in an authoritative reference manual and the British National Formulary [Baxter, 2006; BNF 55, 2008].

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