Is it ever appropriate to be on both Xarelto (rivaroxaban) and Eliquis (apixaban) simultaneously?

From the Guidelines

No, it is never appropriate to take Xarelto (rivaroxaban) and Eliquis (apixaban) simultaneously, as this combination would significantly increase the risk of dangerous bleeding complications without providing additional therapeutic benefit, as both medications are direct oral anticoagulants (DOACs) that work through the same mechanism, inhibiting Factor Xa in the blood clotting cascade 1.

Key Considerations

• The use of dual therapy with anticoagulants, such as rivaroxaban or apixaban, in combination with other antiplatelet agents, is not well established and may increase the risk of bleeding complications, as noted in the 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation 1.
• The European Heart Journal study from 2013 emphasizes the importance of careful management and monitoring of patients on new oral anticoagulants, including consideration of potential drug-drug interactions and bleeding risks 1.
• Taking both Xarelto and Eliquis together would expose patients to an increased risk of bleeding without a clear clinical benefit, as each medication is prescribed at a specific dose to provide the appropriate level of anticoagulation for conditions like atrial fibrillation, deep vein thrombosis, or pulmonary embolism.

Clinical Implications

• Patients should never take both Xarelto and Eliquis together, even for a short period, and should always consult their healthcare provider about any questions regarding their anticoagulation therapy.
• If a patient needs to switch between these medications for any reason, such as side effects or insurance coverage, there should be a carefully managed transition period following specific protocols, typically involving stopping one medication completely before starting the other.
• The potential for increased bleeding risk associated with the concomitant use of anticoagulants and other medications, such as antiplatelet agents or non-steroidal anti-inflammatory drugs (NSAIDs), should be carefully considered and monitored 1.

From the Research

Appropriateness of Concurrent Use of Xarelto and Eliquis

• There is no direct evidence from the provided studies to support the concurrent use of Xarelto (rivaroxaban) and Eliquis (apixaban) for any medical condition 2, 3, 4, 5, 6.
• The studies primarily focus on comparing the efficacy and safety of these anticoagulants individually or against other anticoagulants like warfarin, rather than their combined use 3, 4, 5, 6.
• A study comparing apixaban and rivaroxaban in patients with atrial fibrillation and valvular heart disease found apixaban to be associated with a lower rate of ischemic stroke or systemic embolism and bleeding compared to rivaroxaban, but this does not address the use of both drugs together 5.
• Another study directly comparing dabigatran, rivaroxaban, and apixaban for effectiveness and safety in nonvalvular atrial fibrillation found no differences in the risk of stroke or systemic embolism among the three, but apixaban was associated with a lower risk of major bleeding 6.
• The management of bleeding due to anticoagulants like rivaroxaban and apixaban requires careful adherence to first principles of bleeding care, and unapproved and untested reversal strategies may be required in patients with life-threatening bleeding, highlighting the complexity of managing anticoagulant therapy 2.

Considerations for Anticoagulant Therapy

• The choice of anticoagulant should be based on individual patient factors, including the specific medical condition being treated, the risk of bleeding, and other comorbidities 4, 5, 6.
• There is no evidence to suggest that being on both Xarelto and Eliquis simultaneously is appropriate or safe, and such use could potentially increase the risk of bleeding complications 2, 3, 5, 6.
• Healthcare providers should carefully evaluate the risks and benefits of anticoagulant therapy and select the most appropriate medication for each patient, considering the latest clinical guidelines and evidence-based practices 4, 5, 6.