No, You Cannot Take Dabigatran and Apixaban Together
Taking dabigatran (Pradaxa) and apixaban (Eliquis) simultaneously is absolutely contraindicated and creates an unacceptable risk of life-threatening bleeding. 1
Why Concurrent Use Is Dangerous
Dual anticoagulation creates excessive bleeding risk by combining two direct oral anticoagulants (DOACs) that work through different mechanisms—dabigatran inhibits thrombin directly while apixaban inhibits Factor Xa. 2, 3
No clinical indication exists for combining these agents, as both provide complete anticoagulation independently and combining them offers no therapeutic advantage while dramatically increasing hemorrhagic complications. 4
Major bleeding events are already significant with single-agent DOAC therapy, with rates of 2.8-6.0 per 100 person-years depending on the specific agent, and concurrent use would exponentially increase this risk. 4
The Correct Approach: Direct Switching Without Overlap
When transitioning between dabigatran and apixaban, discontinue dabigatran completely and start apixaban when the next scheduled dabigatran dose would be due—with no overlap, no gap, and no bridging anticoagulation. 1
Key Switching Principles:
Never overlap the two DOACs, as this creates excessive anticoagulation and bleeding risk that cannot be reversed with available antidotes. 1, 2
Do not leave a gap between stopping dabigatran and starting apixaban, as this creates a period of inadequate anticoagulation and thrombotic risk. 1
Both agents provide immediate anticoagulant effect once therapeutic levels are reached, making seamless transition possible without bridging. 1
Dosing Considerations When Switching
For Atrial Fibrillation:
Standard apixaban dose is 5 mg twice daily for most patients. 1
Reduced dose of 2.5 mg twice daily is required if the patient meets at least 2 of these criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1
For VTE Treatment:
- Initial dose is 10 mg twice daily for 7 days, then 5 mg twice daily for continued treatment. 1
Critical Safety Considerations
No antidote exists for either dabigatran or apixaban in early clinical practice, making bleeding management extremely challenging if dual therapy were attempted. 2, 3
Standard coagulation tests (INR, aPTT) do not reliably correlate with DOAC levels, making it impossible to monitor the combined anticoagulant effect if both drugs were used together. 2, 3
Prothrombin complex concentrates and recombinant Factor VII have limited efficacy for reversing DOAC-related bleeding and carry thrombotic risks. 2, 3
Special Populations Requiring Extra Caution
Renal impairment significantly affects both drugs, with dabigatran being ~80% renally eliminated and apixaban requiring dose adjustment in renal dysfunction—assess creatinine clearance before any transition. 5, 1
Elderly patients and those with extremes in body weight are at particularly high bleeding risk with DOACs and would face catastrophic consequences with dual therapy. 2
Drug interactions with P-glycoprotein and CYP3A4 inhibitors affect both agents and must be reviewed when switching, as apixaban may require dose adjustment based on concomitant medications. 5, 1
Common Clinical Pitfall to Avoid
The most dangerous error is assuming that "bridging" between DOACs requires overlap similar to warfarin transitions—this is categorically wrong, as concurrent administration with parenteral anticoagulants or other DOACs is never recommended when switching between direct oral anticoagulants. 1