Apixaban × Rivaroxaban

Apixaban and rivaroxaban are both direct factor Xa inhibitors. Their effects are additive without therapeutic gain. Risk of major bleeding rises sharply.

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.

The combination is not prescribed. When switching between DOACs, stop the first agent and start the second at the time of the next scheduled dose, with no overlap. If a patient inadvertently takes both, observe in hospital for at least 24 hours with haemoglobin and creatinine monitoring.