Anticoagulant | Bioavailability | Metabolism and clearance*¶ | Half-life | Potential for pharmacokinetic drug interactions*¶ |
Dabigatran (Pradaxa) |
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Apixaban (Eliquis) |
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Edoxaban (Savaysa, Lixiana) |
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Rivaroxaban (Xarelto) |
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AF: atrial fibrillation; CrCl: creatinine clearance estimated by the Cockcroft-Gault equation; CYP3A4: cytochrome p450 3A4 isoform; DOAC: direct oral anticoagulant; P-gp: P-glycoprotein drug efflux pump; VTE: venous thromboembolism, includes deep vein thrombosis and pulmonary embolism.
* Examples of P-gp inhibitors that reduce metabolism of DOACs, leading to increased DOAC levels, include clarithromycin, ombitasvir- or ritonavir-containing combinations, and verapamil. Examples of P-gp inducers that increase DOAC metabolism, leading to lower DOAC levels, include phenytoin, rifampin, and St. John's wort. Refer to list available as a separate table in UpToDate.
¶ Examples of strong CYP3A4 inhibitors that reduce metabolism of some DOACs, leading to increased DOAC levels, include clarithromycin and ombitasvir- or ritonavir-containing combinations. Examples of strong CYP3A4 inducers that increase metabolism of some DOACs, leading to lower DOAC levels, include carbamazepine, phenytoin, and rifampin. Refer to list available as a separate table in UpToDate.
Δ In patients with AF, combined use of levetiracetam or valproate with dabigatran, apixaban, or rivaroxaban was associated with an increased risk of ischemic stroke or systemic embolism. The mechanism of this interaction is unknown.[1]
◊ Inhibition of CYP3A4 (ie, without P-gp inhibition) may also increase apixaban and rivaroxaban effect, but to a lesser extent than dual inhibition of CYP3A4 and P-gp. Examples of CYP3A4 inhibitors that do not also inhibit P-gp include diltiazem, fluconazole, and voriconazole. Increased monitoring is advised.
§ Blood levels of edoxaban were reduced and a higher rate of ischemic stroke was observed in patients with AF and CrCl >95 mL/minute who were treated with edoxaban compared with those receiving warfarin. Refer to the UpToDate topic on anticoagulation in AF for additional information.Prepared with data from:
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