Major
Apixaban × Sertraline
Direct oral anticoagulants (factor Xa inhibitors)×Selective serotonin reuptake inhibitors (SSRIs)
Mechanism
Sertraline (SSRI) depletes the platelet serotonin pool and impairs primary haemostasis. Combined with apixaban, upper GI bleeding risk roughly doubles.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, blood in urine or stool, menorrhagia. Severe cases include gastrointestinal or intracranial haemorrhage. Risk rises in patients over 65 and with prior peptic ulcer disease.
Management
The combination is acceptable when antidepressant therapy is needed. PPI cover with pantoprazole is advisable. Alternative antidepressants with minimal platelet effect: mirtazapine or agomelatine.
Sources
- Lexicomp: Lexicomp Drug Interactions (2024)– Wolters Kluwer Clinical Drug Information, Inc. Lexi-Interact Online, 2024
- Pharmaceutical Press: Stockley's Drug Interactions, 12th edition (2024)– Preston CL (ed.). Stockley's Drug Interactions. 12th ed. London: Pharmaceutical Press; 2024