Moderate
Apixaban × venlafaxine
Direct oral anticoagulants (factor Xa inhibitors)×SNRI (serotonin-norepinephrine reuptake inhibitor)
Mechanism
Venlafaxine (SNRI) moderately 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. Venlafaxine also raises blood pressure at doses above 150 mg/day — consider alternatives in arterial hypertension.