From the Guidelines
Azithromycin (Z-pack) and Eliquis (apixaban) can be taken together, but careful monitoring is required due to potential interactions, as azithromycin may slightly increase blood levels of apixaban, potentially enhancing its blood-thinning effects 1. When considering the use of azithromycin with apixaban, it's essential to weigh the benefits against the potential risks. The primary concern is the increased risk of bleeding due to the potential interaction between the two medications.
- Azithromycin is a P-gp inhibitor, which can increase the maximum concentration (Cmax) and area under the curve (AUC∞) of apixaban, leading to an increased risk of bleeding 1.
- However, the effect of azithromycin on apixaban metabolism is less pronounced compared to strong CYP3A4 inhibitors, and the clinical significance of this interaction is still being researched 1.
- A retrospective study found that clarithromycin, a strong CYP3A4 and P-gp inhibitor, was associated with a higher incidence of hospitalization for major bleeding in patients taking DOACs, including apixaban, compared to azithromycin 1.
- Experts recommend avoiding the combination of apixaban with strong CYP3A4 and P-gp inhibitors, but if the combination is unavoidable, reducing the dose of apixaban by 50% may be necessary 1. To minimize the risks, patients taking both azithromycin and apixaban should:
- Inform all healthcare providers about all medications they are taking
- Watch for unusual bleeding signs, such as excessive bruising, nosebleeds, blood in urine or stool, or unusually heavy menstrual bleeding
- Contact their healthcare provider immediately if they experience concerning symptoms, rather than discontinuing either medication on their own
- Continue taking their Eliquis as directed without interruption, as stopping anticoagulation therapy can increase stroke risk.
From the Research
Zpack and Eliquis Interaction
- There is no direct evidence of an interaction between Zpack (azithromycin) and Eliquis (apixaban) in the provided studies.
- However, studies have investigated the pharmacokinetics of azithromycin in patients with renal impairment 2 and the safety and efficacy of apixaban in patients with severe renal impairment 3, 4, 5, 6.
- Azithromycin pharmacokinetics are not significantly affected by renal insufficiency, suggesting that the dosage regimen may be the same as in patients with normal renal function 2.
- Apixaban has been shown to be a reasonable alternative to warfarin in patients with severe renal impairment, with a lower risk of bleeding in some studies 4, 5, 6.
Renal Impairment Considerations
- Patients with renal impairment may require careful consideration when using anticoagulants like apixaban, as the risk of bleeding may be increased 3, 4, 5, 6.
- The studies suggest that apixaban may be a safer option than warfarin in patients with severe renal impairment, but clinicians should monitor for signs of bleeding throughout the duration of therapy 5.
- The interaction between Zpack and Eliquis is not directly addressed in the provided studies, but clinicians should be aware of the potential risks and benefits of using these medications in patients with renal impairment.