Aspirin is one of those drugs you probably consider innocuous, and most of us keep a bottle of it on hand for aches and pains. But this over-the-counter medicine is more potent than you think. “Many people assume aspirin is harmless because it can be purchased without a prescription, but that is not entirely true,” says Cavan O’Kane, Pharm.D., BCPS, BCGP, CTTS, a clinical pharmacy specialist at the Medication Management Clinic at Cooper University Health Care. “Even low doses of aspirin (81 mg) can increase the risk of stomach bleeding and ulcers and bleeding in the brain, which is rare, but serious.”
Why is aspirin risky to mix with?
Aspirin belongs to the family of nonsteroidal anti-inflammatory drugs (NSAIDs). “Think of ibuprofen or naproxen; these are also NSAIDs,” says Mark Karasin, DNP, APN, RN, AGACNP-BC, CNOR(E), an assistant professor and specialty director for the Adult-Gerontology Acute Care Nurse Practitioner Programs at the Rutgers School of Nursing. “These medications work on cyclooxygenase (COX) enzymes to produce the desired effect. What makes aspirin stand out from its cousins is its effect on platelets, disk-shaped blood cells that stick together like a mesh to form clots when you get a cut. Aspirin deactivates this clumping property, and so, as clinicians, we often think of aspirin as a blood thinner.”
These blood-thinning properties are what can be problematic when aspirin is mixed with certain other drugs and substances. “The risk of bleeding increases as individuals get older, especially after the age of 60,” says O’Kane. “Because of these risks, aspirin is not recommended for everyone.”
This is why it’s important to discuss aspirin use with your doctor. “We often miss this critical step of having an open conversation with our healthcare provider about the important details of all prescribed medications, over-the-counter drugs, vitamins, and supplements,” says Karasin. “Aspirin feels familiar because it has been around for generations. However, being common and not requiring a prescription does not make it harmless. Aspirin is still a powerful medication that can cause real harm if used improperly.”
What to avoid when using aspirin
Because many of us take both prescription and over-the-counter drugs or supplements, here’s what you shouldn’t mix with aspirin:
Blood Thinners
Drugs such as warfarin (Coumadin), apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), clopidogrel (Plavix), ticagrelor (Brilinta), and prasugrel (Effient) should not be mixed with aspirin use. “Taking aspirin with these medications can significantly increase the risk of dangerous or serious bleeding,” says O’Kane. “Sometimes these combinations are necessary but should be used under medical supervision because the bleeding risk is much higher.”
Other NSAIDs
Taking other nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin) and naproxen (Aleve) with aspirin carries an increased risk of irritating the stomach lining. “Stacking it with ibuprofen or naproxen may exacerbate conditions like peptic ulcer disease or reflux and lead to oozing from the stomach,” says Karasin. “A good rule is to always question taking two types of medications from the same category.”
Antidepressants
Some antidepressants such as fluoxetine (Prozac) and sertraline (Zoloft) and to a much lower extent, escitalopram (Lexapro) or citalopram (Celexa), can elevate the risk of bleeding. They typically do not have to be avoided, but there should always be a discussion with your doctor about aspirin usage with these medications, says Karasin.
Steroids
Unfortunately, medications such as prednisone and methylprednisolone may increase the risk of stomach irritation and bleeding when taken with aspirin, says O’Kane.
Over-the-counter supplements
Some supplements can also increase bleeding risk such as ginkgo biloba, garlic supplements, fish oil (especially higher doses), and vitamin E, so they’re not recommended for use in combination with aspirin, says O’Kane.
Other OTC medications for headaches, colds, allergies, and heartburn
It may sound surprising, but it’s smart to look at the contents of specific over-the-counter products that are used for headaches (such as Excedrin), cold and flu (such as Alka-Seltzer), allergies, congestion, heartburn, and upset stomach as they may be co-formulated with aspirin or an NSAID, says O’Kane.
Alcohol
Although most foods are fine with aspirin (including grapefruit!), one major dietary precaution stands above the rest: alcohol. It can irritate the stomach and increase the risk of stomach bleeding.
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The bottom line
Combining aspirin with some common prescription and over-the-counter medications can cause dangerous interactions, namely, bleeding issues. “This is why it is critical to discuss the use of aspirin with your healthcare provider, especially before starting or stopping it,” says Karasin.
You also should tell all your providers that you use aspirin—including your dentist—so they’re aware of any potential risks to you during treatment. “Aspirin can be very helpful for some people, but it isn’t risk-free,” says O’Kane.
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