“Direct oral anticoagulants (DOACs) have fewer drug interactions than warfarin, but interactions do occur. In a large series involving nearly 100,000 individuals receiving a DOAC, individuals receiving apixaban plus fluconazole, a moderate inhibitor of the P450 cytochrome CYP3A4, had a 3.5-fold increased risk of bleeding compared with periods when they were receiving apixaban without fluconazole [1]. The increase was greatest in gastrointestinal bleeding requiring hospitalization. The risk was only seen with systemic fluconazole plus apixaban; it did not occur with topical fluconazole plus apixaban or systemic fluconazole plus another DOAC.
This study highlights the importance of possible drug interactions and of considering alternatives that might be equally effective, such as topical therapy. (See “Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects”, section on ‘Dosing, monitoring, risks (apixaban)’.)”
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