Is it safe to take Eliquis (apixaban) and Lexapro (escitalopram) together?

Combining Eliquis and Lexapro: Safety Assessment

Yes, it is generally safe to take Eliquis (apixaban) and Lexapro (escitalopram) together, as escitalopram does not significantly interact with the metabolic pathways or transporters that affect apixaban levels. However, there is a documented increased bleeding risk when these medications are combined that requires clinical awareness.

Pharmacokinetic Compatibility

The combination does not produce clinically significant drug-drug interactions through metabolic pathways:

• Apixaban is metabolized primarily through CYP3A4 and is a substrate of P-glycoprotein (P-gp) transporters 1
• Escitalopram is metabolized by CYP2C19, CYP2D6, and CYP3A4, but in vitro studies demonstrate it has negligible inhibitory effects on CYP isoenzymes and P-glycoprotein 2
• Escitalopram and citalopram have been studied and can be safely combined with anticoagulant therapy from a pharmacokinetic perspective 1

Bleeding Risk Consideration

Despite the lack of pharmacokinetic interaction, there is an additive pharmacodynamic bleeding risk:

• A case report documented a limb-threatening hematoma in an 85-year-old patient taking citalopram (the racemic form of escitalopram) and apixaban concurrently, attributed to synergistic anticoagulant effects 3
• SSRIs like escitalopram can impair platelet function by depleting intraplatelet serotonin, which is necessary for normal platelet aggregation
• This represents a pharmacodynamic interaction (additive bleeding risk) rather than a pharmacokinetic interaction (altered drug levels)

Clinical Management Recommendations

When prescribing these medications together, implement the following monitoring strategy:

• Counsel patients specifically about signs of bleeding: unusual bruising, prolonged bleeding from cuts, blood in urine or stool, severe headaches, or unexplained swelling 3
• Pay particular attention to elderly patients (>75 years), who have elevated baseline bleeding risk with apixaban 1
• Consider the patient's overall bleeding risk profile, including renal function, weight, and concomitant medications 1
• No dose adjustment of either medication is required based solely on their combination 1, 2

Important Clinical Caveats

Several patient-specific factors warrant heightened vigilance:

• Patients with renal impairment (CrCl <50 mL/min) already require careful apixaban monitoring and may be at higher bleeding risk when SSRIs are added 1
• Patients weighing <50 kg have increased apixaban exposure and should be monitored more closely when starting escitalopram 1
• The combination should be used cautiously in patients with history of gastrointestinal bleeding or those taking other medications that affect hemostasis (NSAIDs, antiplatelet agents) 1

When to Avoid Strong Interacting Medications

Unlike escitalopram, certain medications require apixaban dose reduction or avoidance:

• Strong dual inhibitors of both CYP3A4 and P-gp (such as ketoconazole, clarithromycin) require 50% apixaban dose reduction 1
• Strong inducers of CYP3A4 or P-gp (such as rifampin) should be avoided with apixaban due to reduced efficacy 1
• Escitalopram does not fall into either of these categories 2