From the Guidelines
Taking fish oil supplements while on Xarelto (rivaroxaban) requires caution due to potential increased bleeding risk, but there is no strong evidence to suggest a significant interaction between the two, and the decision to use them together should be made on a case-by-case basis, considering the patient's individual bleeding risk factors and under medical supervision. Both fish oil and Xarelto have blood-thinning effects that may compound when used together. If you're taking Xarelto, consult your healthcare provider before starting fish oil supplements, especially at doses above 1 gram daily. Your doctor may need to monitor you more closely for signs of bleeding or adjust your treatment plan. The concern stems from fish oil's omega-3 fatty acids (EPA and DHA), which can inhibit platelet aggregation and potentially enhance the anticoagulant effect of Xarelto, which already works by blocking clotting factor Xa. According to the 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation 1, there are no pharmacokinetic data on fish oil supplements for any of the NOACs, but interaction is unlikely.
Some key points to consider:
- Fish oil supplements are generally well-tolerated, with mild gastrointestinal effects being the most common side effect 1.
- There is some evidence to suggest that fish oil may have protective effects against chemotherapy-induced toxicities, such as peripheral neuropathy 1.
- However, the use of fish oil supplements in patients taking Xarelto should be approached with caution, and patients should be closely monitored for signs of bleeding or other adverse effects.
- The European Food Safety Authority (EFSA) has concluded that long-term supplemental intakes of EPA and DHA combined up to about 5 g/day do not appear to increase the risk of spontaneous bleeding episodes or bleeding complications 1.
- A weak recommendation for the use of fish oil and long-chain N-3 fatty acids has been made due to the inconsistencies in the reported effects, but with several positive trials published during the last few years reporting nutritional benefits, a plausible biological rationale, only mild side effects and no convincingly serious safety issues 1.
Common signs of excessive anticoagulation to watch for include unusual bruising, nosebleeds, bleeding gums, or blood in urine or stool. Never stop taking Xarelto without medical guidance, as this could increase your risk of dangerous blood clots. The most recent and highest quality study on this topic is from 2021, which provides guidance on the use of fish oil supplements in patients with cancer, but does not specifically address the interaction between fish oil and Xarelto 1.
From the Research
Interaction between Fish Oil and Xarelto (Rivaroxaban)
- The interaction between fish oil and Xarelto (rivaroxaban) is not directly addressed in the provided studies, but we can look at the effects of fish oil on bleeding risk and the pharmacology of rivaroxaban to understand potential interactions.
- Fish oil supplements have been shown to reduce platelet aggregation in healthy subjects 2, but this effect does not seem to increase the risk of bleeding during or after surgery 2.
- Studies have also investigated the combination of fish oil with other antithrombotic agents, such as aspirin and clopidogrel, and found no significant increase in bleeding risk 3.
- Rivaroxaban, a direct oral Factor Xa inhibitor, has a predictable pharmacokinetics and pharmacodynamics profile, and its dosing regimens vary depending on the indication 4.
- The benefit-risk profile of rivaroxaban has been evaluated in several studies, and it appears to demonstrate a favorable profile across multiple clinical indications 5.
- However, it is essential to note that the potential interaction between fish oil and rivaroxaban has not been specifically studied, and therefore, no definitive conclusions can be drawn.
- Based on the available evidence, it seems that fish oil supplements may not significantly increase the risk of bleeding when combined with antithrombotic agents, but the specific interaction with rivaroxaban remains unclear 6, 3, 2.