Moderate
Apixaban × fluvoxamine
Direct oral anticoagulants (factor Xa inhibitors)×SSRI
Mechanism
Fluvoxamine impairs primary haemostasis by inhibiting platelet serotonin reuptake. Additively with the direct factor Xa inhibitor apixaban, GI bleeding risk rises by 30–50%.
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 for short courses. If long-term SSRI is needed, in patients over 65 or with prior peptic ulcer add gastroprotection (pantoprazole 20 mg/day). Antidepressant alternatives without platelet effect: mirtazapine, agomelatine, trazodone.