Moderate
Apixaban × Verapamil
Direct oral anticoagulants (factor Xa inhibitors)×Non-dihydropyridine calcium channel blocker
Mechanism
Verapamil moderately inhibits CYP3A4 and P-glycoprotein. Apixaban AUC rises by 30–50%, increasing bleeding risk.
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
At standard apixaban dose (5 mg twice daily), the combination is acceptable in patients under 75 with normal renal function. In older patients, creatinine clearance below 50 mL/min, or body weight below 60 kg, reduce apixaban to 2.5 mg twice daily. Antihypertensive alternatives: diltiazem with the same precaution, or a beta-blocker without CYP3A4 effect (metoprolol, bisoprolol).