From the Guidelines
Patients can generally take diltiazem and Xarelto (rivaroxaban) at the same time, but this combination requires careful monitoring. According to a 2022 study published in Circulation: Arrhythmia and Electrophysiology 1, diltiazem did not significantly increase plasma concentrations of apixaban, and may be a more suitable combination in some circumstances. Although this study specifically mentions apixaban, not rivaroxaban, it suggests that diltiazem may be a safer option compared to other calcium channel blockers like verapamil, which is a potent inhibitor of P-gp.
When considering the use of diltiazem and Xarelto together, it's essential to monitor patients for signs of bleeding, such as unusual bruising, nosebleeds, blood in urine or stool, or prolonged bleeding from cuts. Diltiazem is a moderate inhibitor of CYP3A4, an enzyme that metabolizes rivaroxaban, which can potentially increase rivaroxaban levels in the blood. However, no specific dose adjustment for rivaroxaban is routinely recommended when used with diltiazem, but healthcare providers may consider a lower rivaroxaban dose in patients with additional risk factors for bleeding or those with kidney impairment, as reported in the study 1.
Key considerations for healthcare providers include:
- Monitoring patients for signs of bleeding
- Informing patients about the potential risks and benefits of this combination
- Adjusting rivaroxaban doses as needed in patients with additional risk factors for bleeding or kidney impairment
- Regular follow-up appointments to monitor for any adverse effects from this combination.
From the Research
Patient Considerations for Diltiazem and Xarelto (Rivaroxaban) Co-Prescription
- Patients can be prescribed diltiazem and Xarelto (rivaroxaban) at the same time, but the decision should be made with caution due to potential increased bleeding risk 2, 3, 4.
- Studies have shown that concomitant use of diltiazem with direct oral anticoagulants (DOACs), including rivaroxaban, may increase the risk of bleeding events, particularly in patients with atrial fibrillation 2, 3, 4.
- However, one study found no significant difference in bleeding events between patients taking rivaroxaban with diltiazem and those taking rivaroxaban alone 5.
Bleeding Risk Considerations
- The risk of bleeding may be higher in patients taking diltiazem with rivaroxaban, especially in those with chronic kidney disease or those taking higher doses of diltiazem 2, 4.
- Patients should be closely monitored for signs of bleeding, and the benefits of concomitant therapy should be weighed against the potential risks 2, 4.
- The choice of anticoagulant and concomitant medications should be individualized based on patient-specific factors, including kidney function, bleeding risk, and other comorbidities 3, 4.
Clinical Implications
- Clinicians should be aware of the potential increased bleeding risk associated with concomitant use of diltiazem and rivaroxaban, and should carefully consider the benefits and risks of this combination in patients with atrial fibrillation 2, 3, 4.
- Patients taking diltiazem and rivaroxaban should be closely monitored for signs of bleeding, and should be educated on the potential risks and benefits of this combination 2, 4.