Moderate
Apixaban × Fluoxetine
Direct oral anticoagulants (factor Xa inhibitors)×Selective serotonin reuptake inhibitors
Mechanism
Fluoxetine, like other SSRIs, impairs primary haemostasis by inhibiting platelet serotonin reuptake. Additively with apixaban, GI bleeding risk rises.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, black or tarry stools, haematuria. Higher risk in older patients, prior peptic ulcer disease, and chronic kidney disease.
Management
The combination is acceptable. In patients over 65 or with prior peptic ulcer: pantoprazole 20 mg/day. The long half-life of fluoxetine and its active metabolite norfluoxetine (4–6 days) prolongs bleeding risk for another 4–6 weeks after discontinuation.