Critical
Apixaban × Dabigatran
Direct oral anticoagulants (factor Xa inhibitors)×Direct thrombin inhibitor
Mechanism
Apixaban inhibits factor Xa; dabigatran inhibits thrombin. Additive anticoagulation with no therapeutic benefit and high risk of major bleeding.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, blood in urine or stool, menorrhagia. Severe cases include gastrointestinal or intracranial haemorrhage, gross haematuria with renal colic, spontaneous retroperitoneal haematomas. Symptoms may appear within days of co-prescription.
Management
The combination is not prescribed. When switching DOACs, stop the first and start the second at the next scheduled dose. Overlap is only acceptable via a parenteral anticoagulant when bridging is needed.