Concurrent Use of Eliquis (Apixaban) 5mg and Flecainide 50mg
Yes, it is safe to administer apixaban 5mg and flecainide 50mg together—there is no clinically significant drug-drug interaction between these medications. 1
No Direct Pharmacokinetic Interaction
- Flecainide does not inhibit or induce CYP3A4 or P-glycoprotein (P-gp), the primary metabolic pathways for apixaban elimination. 1
- The 2018 European Heart Rhythm Association guidelines specifically address antiarrhythmic drugs with NOACs and do not list flecainide as having any interaction with apixaban. 1
- Apixaban is metabolized via CYP3A4 (approximately 27% of clearance) and is a substrate of P-gp and BCRP transporters, but flecainide does not affect these pathways. 2
Important Distinction from Other Antiarrhythmics
- Amiodarone is different—it significantly increases apixaban exposure and bleeding risk, with a rate difference of 17.5 bleeding events per 1000 person-years compared to flecainide or sotalol. 3
- Dronedarone is contraindicated with some NOACs due to strong P-gp inhibition, but flecainide lacks this mechanism. 1
- The comparative safety study specifically used flecainide as the "safe comparator" antiarrhythmic when evaluating bleeding risk with apixaban, confirming its favorable interaction profile. 3
Clinical Evidence Supporting Safety
- A large retrospective cohort study of 91,590 Medicare patients with atrial fibrillation demonstrated that flecainide (along with sotalol) had significantly lower bleeding-related hospitalizations compared to amiodarone when used with apixaban or rivaroxaban. 3
- Flecainide is recommended as first-line therapy for rhythm control in patients without structural heart disease and is commonly used alongside anticoagulation. 4
Practical Considerations
- No dose adjustment of either medication is required when used together. 1
- Continue standard apixaban dosing (5mg twice daily) unless the patient meets specific dose-reduction criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 5
- Monitor for bleeding as you would with any anticoagulant therapy, but the combination itself does not increase bleeding risk beyond apixaban alone. 3
Contraindications to Note Separately
- Ensure flecainide is appropriate for the patient (no structural heart disease, no severe renal impairment, no history of myocardial infarction). 4
- Verify apixaban dosing is appropriate based on renal function, age, and weight criteria. 6, 5
- The only anticoagulant-related contraindication with flecainide involves lopinavir/ritonavir (HIV protease inhibitor), which is contraindicated due to potential cardiac arrhythmias—this is unrelated to apixaban. 1