Major
Clopidogrel × Rivaroxaban
Antiplatelet agents – P2Y12 receptor inhibitors×Direct oral anticoagulants (factor Xa inhibitors)
Mechanism
Clopidogrel blocks the platelet P2Y12 receptor; rivaroxaban directly inhibits factor Xa. The two antithrombotic mechanisms add up, roughly doubling major bleeding risk.
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
Dual therapy is used after acute coronary syndrome or stenting in atrial fibrillation, generally for no more than 1–6 months. Rivaroxaban dose is adjusted to age and renal function. PPI cover with pantoprazole is mandatory.