OBJECT DRUGS
Anticoagulants, Oral:
- Apixaban (Eliquis)
- Rivaroxaban (Xarelto)
PRECIPITANT DRUGS
Antimicrobials:
- Ciprofloxacin (Cipro, etc.)
- Clarithromycin (Biaxin, etc.)
- Erythromycin (E-Mycin, etc.)
- Fluconazole (Diflucan)
- Isoniazid (INH)
- Itraconazole (Sporanox, etc.)
- Ketoconazole (Nizoral, etc.)
- Posaconazole (Noxafil)
- Quinupristin (Synercid)
- Telithromycin (Ketek)
- Troleandomycin (TAO)
- Voriconazole (Vfend)
Comment:
These antimicrobials inhibit CYP3A4 and may increase the plasma concentration of apixaban and rivaroxaban. Since apixaban and rivaroxaban are also substrates for P-glycoprotein, precipitant drugs that inhibit both CYP3A4 and P-glycoprotein may produce a larger increase in anticoagulant concentrations.
Class 3: Assess Risk & Take Action if Necessary
- Consider Alternative:
- Azole Antifungals: Fluconazole appears to be a less potent inhibitor of CYP3A4; but in larger doses it also inhibits CYP3A4. Terbinafine (Lamisil) does not appear to affect CYP3A4.
- Macrolide Antibiotics: Azithromycin (Zithromax) and dirithromycin* do not appear to inhibit CYP3A4 and are unlikely to interact. (*not available in US).
- Monitor: Monitor for altered rivaroxaban effect if one of these antimicrobials is initiated, discontinued or changed in dosage; adjustments of rivaroxaban dosage may be needed. If rivaroxaban is initiated in the presence of therapy with one of these agents, consider conservative doses of rivaroxaban.