I got asked a question the other day about a drug interaction program flagging a drug interaction between apixaban and sertraline. There are definitely a few factors that make the apixaban sertraline interaction a challenging one to manage. Here’s a few thoughts on what I think about.
- With apixaban being a somewhat newer agent, experience is limited, so that in itself can be a challenge. The evidence for how clinically significant this interaction is can be difficult to find.
- What is the mechanism? The most likely concern with sertraline is its ability to inhibit platelets and increase the risk of bleeding with the oral anticoagulant apixaban. Here’s a reference that discusses the antiplatelet activity of sertraline and how theorhetically it could increase the risk of bleed.
- What dose are we considering? From the reference above, the platelet inhibition effect from sertraline is dose dependent. The higher the dose, the more likely you will have platelet inhibition.
- Can we select an alternative antidepressant. This may or may not be appropriate given the circumstances, but it is a very pertinent question to ask.
- Monitor and educate. Letting patients know that there could be an increased risk of bleeding in using these two medications together is always a good idea as patients can help monitor for increased bruising or bleeding. This is probably the course of action most providers will take in managing this interaction, but there are numerous factors that could alter that assessment.
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We turned this alert off in our EHR – some questions that come to mind:
Would you have the same level of concern with warfarin and/or enoxaparin with sertraline?
Are the other SSRIs, SNRIs, etc “safer” in this regard compared to sertraline?
Do you have access to an Anti-Xa level?
Both meds are presumably important, this is one of those interactions I have a tough time intervening on unless the patient is here with GI Bleed.
Sertralin in a strong Pgp inhibitor and apixaban a
Known substrate of this Pgp , so ,aside from the antiplatelet effect of sertralin, this SSRIs may expose the patient to higher blood level of apixaban……sorry for my english folks
I have recently started Apixaban because of clots on my lungs but am also suffering from terrible anxiety which my GP has given me Sertraline 50mg to take, how concerned should I be about combining these two drugs?
Definitely a good opportunity to have a discussion with your provider.