From the Guidelines
When taking Eliquis (apixaban), lithium and valproate are the most compatible mood stabilizers, as they have minimal interactions with apixaban, whereas strong CYP3A4 and P-gp inhibitors, such as carbamazepine, should be avoided due to increased risk of bleeding or reduced apixaban efficacy 1.
Mood Stabilizer Options
- Lithium is considered a safe option with minimal interaction with Eliquis, and can be started at 300mg twice daily, with gradual titration to therapeutic levels (0.6-1.2 mmol/L) 1.
- Valproate (Depakote) at 250-500mg twice daily is another reasonable choice, though it may slightly increase bleeding risk, but no significant interaction with apixaban has been reported 1.
- Lamotrigine can be used with caution, starting at 25mg daily with a slow titration schedule over 6-8 weeks to reach 100-200mg daily, as it is a moderate CYP3A4 and P-gp inhibitor, but its effect on apixaban is less pronounced 1.
- Carbamazepine should be avoided as it is a strong CYP3A4 and P-gp inducer, which can significantly reduce Eliquis effectiveness 1.
- Newer antipsychotics like quetiapine (50-300mg daily) or aripiprazole (5-15mg daily) can also provide mood stabilization with minimal interaction with Eliquis, but their use should be carefully monitored 1.
Monitoring and Precautions
Regular blood tests to monitor drug levels and clotting parameters are essential when using mood stabilizers with Eliquis, and any unusual bleeding or bruising should prompt immediate medical attention 1. The choice of mood stabilizer should ultimately be based on your specific mood disorder, previous medication response, and overall health status. It is crucial to avoid strong CYP3A4 and P-gp inhibitors, such as clarithromycin, and inducers, such as rifampin, when taking apixaban, as they can significantly increase the risk of bleeding or reduce apixaban efficacy 1.
From the Research
Mood Stabilizers and Eliquis (Apixaban) Compatibility
There are no direct studies on the compatibility of mood stabilizers with Eliquis (apixaban) in the provided evidence. However, we can look at the pharmacokinetics and potential interactions of mood stabilizers to assess possible compatibility issues.
Pharmacokinetics of Mood Stabilizers
- Lithium has a low therapeutic index and is renally excreted, which may lead to renally-mediated drug-drug interactions 2, 3, 4.
- Carbamazepine has a low therapeutic index, is metabolized primarily by CYP3A3/4, and has an active epoxide metabolite, making it susceptible to CYP3A3/4 or epoxide hydrolase inhibitors 3, 4.
- Valproate has less prominent neurotoxicity and three principal metabolic pathways, rendering it less susceptible to toxicity due to inhibition of its metabolism 3, 4.
- Newer anticonvulsants such as lamotrigine, topiramate, and tiagabine have different hepatically-mediated drug-drug interactions 3, 4.
- Gabapentin is renally excreted and lacks hepatic drug-drug interactions, but may have reduced bioavailability at higher doses 3, 4.
Potential Interactions with Eliquis (Apixaban)
- Apixaban is a direct oral anticoagulant that works by inhibiting factor Xa. Its metabolism is primarily hepatic, via CYP3A4 and to a lesser extent via CYP1A2 and CYP2J2.
- Potential interactions between mood stabilizers and apixaban may occur through CYP3A4 inhibition or induction, which could affect apixaban's plasma concentrations.
- However, without direct studies on the compatibility of mood stabilizers with Eliquis (apixaban), it is difficult to determine the extent of these potential interactions.
Clinical Considerations
- Clinicians should be aware of the potential for drug-drug interactions between mood stabilizers and apixaban, and monitor patients closely for signs of adverse effects or changes in therapeutic efficacy.
- Dose adjustments or alternative treatments may be necessary to minimize the risk of interactions and ensure optimal therapeutic outcomes 5.