Can a patient be on both Eliquis (apixaban) and Xarelto (rivaroxaban) at the same time?

Concurrent Use of Eliquis and Xarelto is Contraindicated

Patients should never be on both Eliquis (apixaban) and Xarelto (rivaroxaban) simultaneously as this combination would significantly increase bleeding risk without additional therapeutic benefit. 1

Rationale for Contraindication

Both medications are direct oral anticoagulants (DOACs) that work through similar mechanisms:

• Apixaban (Eliquis) and rivaroxaban (Xarelto) are both direct factor Xa inhibitors
• They have overlapping anticoagulant effects
• Combining them would create redundant anticoagulation with additive bleeding risk

Pharmacological Considerations

1. Metabolism and Drug Interactions:

   • Rivaroxaban is primarily metabolized via CYP3A4 and is a substrate for P-glycoprotein 1
   • Apixaban is also metabolized via CYP3A4 and is a substrate for both P-glycoprotein and BCRP 2
   • Using both simultaneously would create complex drug interaction patterns

2. Bleeding Risk:

   • Even when used individually, both medications carry significant bleeding risk
   • Recent studies show apixaban has a lower bleeding risk than rivaroxaban when used alone 3, 4
   • Combined use would substantially increase this risk without clinical justification

Appropriate Anticoagulation Approaches

If a patient appears to be prescribed both medications, consider these alternatives:

Option 1: Select a Single DOAC

• Choose one DOAC based on patient characteristics:
  • Apixaban may be preferred for patients with higher bleeding risk 4
  • Recent studies show apixaban is associated with lower rates of major bleeding compared to rivaroxaban (2.9% vs 4.2% per year in high-risk patients) 4
  • Apixaban has been associated with lower risk for both ischemic stroke/systemic embolism (HR 0.57) and bleeding (HR 0.51) compared to rivaroxaban in patients with AF and valvular heart disease 5

Option 2: Switch to Different Anticoagulation Strategy

• Consider warfarin if DOACs are contraindicated
• Consider LMWH for certain indications (e.g., cancer-associated thrombosis)

Monitoring Recommendations

For patients on a single DOAC:

• Regular assessment of renal function (at least yearly)
• More frequent monitoring during acute illness or hospitalization
• Monitor for signs of bleeding (unexplained bruising, blood in urine/stool)
• Assess for drug interactions with each medication change

Common Pitfalls to Avoid

1. Transition errors: When switching between anticoagulants, ensure proper timing to avoid periods of either under- or over-anticoagulation

2. Medication reconciliation errors: Carefully verify medication lists, especially during care transitions, to prevent inadvertent dual therapy

3. Failure to recognize drug interactions: Both DOACs have significant interaction profiles that must be monitored:

   • Strong dual inhibitors of CYP3A4 and P-gp (ketoconazole, HIV protease inhibitors) can increase DOAC levels 1
   • Some medications may require dose adjustments of the selected DOAC

4. Inappropriate dosing: Ensure proper dosing of the selected DOAC based on:

   • Age
   • Weight
   • Renal function
   • Concomitant medications

In conclusion, there is no clinical scenario where concurrent use of Eliquis and Xarelto would be appropriate. If a patient appears to be on both medications, this should be addressed immediately by selecting a single appropriate anticoagulant based on the patient's specific clinical needs and risk factors.