Apixaban and Berotralstat: Interaction Details
AI-assisted, pharmacist-reviewed · AI content regenerated Aug 8, 2026 · Source data updated Jul 11, 2026 · Sources: FDA labeling, DDInter 2.0, cited literature
Berotralstat
Apixaban
How we grade severity & evidence
Severity levels
- Contraindicated: These should generally not be used together.
- Major: Potentially serious — often needs a change or close monitoring.
- Moderate: Can be significant — usually manageable with monitoring.
- Minor: Usually limited clinical impact.
Evidence grades
- Established: Well documented — supported by controlled studies or strong clinical data.
- Probable: Good supporting evidence, though not definitively proven.
- Suspected: Some evidence suggests this interaction, but it is not well established.
- Possible: Limited or conflicting evidence; the interaction may occur.
- Theoretical: Predicted from the drugs' pharmacology; not yet confirmed in people.
Ratings come from the documented interaction literature and are reviewed by a pharmacist. They describe the documented risk of the combination, not what will necessarily happen to you — your dose, timing, and health picture all matter.
Here's what's going on. Berotralstat (Orladeyo) can slow down a protein in your body called P-gp that helps move certain drugs out. Apixaban (Eliquis) is a blood thinner that partly relies on that same protein. So taking them together may let a bit more apixaban build up in your body.
Because apixaban thins your blood, higher levels could mean a greater chance of bruising or bleeding. This does not mean you should change anything on your own. Your care team can manage this easily by watching you a little more closely or adjusting your dose if needed. Just let them know you take both.
Mechanism: Berotralstat inhibits P-glycoprotein (P-gp)-mediated efflux. Apixaban is a P-gp substrate, so co-administration may increase apixaban exposure (AUC/Cmax), raising bleeding risk. Neither drug is a prodrug; the direction is increased substrate effect.
- Direction: increased apixaban exposure and anticoagulant effect
- Evidence: probable; P-gp inhibition documented at 2x the max 150 mg berotralstat dose
- Onset: unspecified
- Management: avoid higher-than-recommended berotralstat dosing; monitor for bleeding/bruising; the apixaban dose may need to be individualized by the care team per label and patient factors (renal function, age, weight).
What happens
Increased P-gp substrate exposure
Interaction Deep Dive
When given at twice the 150 mg maximum recommended dose, berotralstat acts as an inhibitor of P-gp. Taking berotralstat together with substrates of P-gp may raise the exposure of those substrates, which can heighten the likelihood of adverse reactions linked to the substrates. Doses of berotralstat above the recommended level are not advised. The P-gp substrate should be closely monitored or its dosage adjusted1.
Why it happens (mechanism)
Inhibition of P-gp-mediated efflux transport by berotralstat
How to manage this interaction
The good news: this is manageable. Keep taking both medications exactly as prescribed unless your prescriber tells you otherwise.
- Your care team may monitor you more closely for signs of bleeding.
- The apixaban dose may be adjusted and individualized by your team if needed.
- Berotralstat should not be used above its recommended dose.
- Watch for and report unusual bruising, nosebleeds, blood in urine or stool, black stools, or bleeding that won't stop.
Tell your pharmacist or doctor that you take both so they can keep an eye on things.
Management is individual — confirm any change with your pharmacist or prescriber.
Literature reports
1 report — tap to read
a) In a drug interaction study, giving berotralstat together with digoxin at a dose of 300 mg raised the AUC by roughly 1.5 fold and the Cmax by roughly 1.5 fold 1.
Common questions
Can I take Apixaban and Berotralstat together?
Berotralstat can raise apixaban levels and increase bleeding risk, so keep taking both as prescribed and let your care team monitor you or adjust your apixaban dose as needed. Always confirm with your pharmacist or prescriber before making any change.
How serious is the Apixaban and Berotralstat interaction?
It is rated major. Potentially serious — often needs a change or close monitoring.
How quickly could this interaction happen?
The documented onset is "unspecified". The timing of this interaction is not well characterized.
How is the Apixaban and Berotralstat interaction managed?
The good news: this is manageable. Keep taking both medications exactly as prescribed unless your prescriber tells you otherwise. Your care team may monitor you more closely for signs of bleeding. The apixaban dose may be adjusted and individualized by your team if needed. Berotralstat should not be used above its recommended dose. Watch for and report unusual bruising, nosebleeds, blood in urine… Management is individual — always follow your own care team's guidance.
How strong is the evidence for this interaction?
The evidence is graded "probable". Good supporting evidence, though not definitively proven.
From our Q&A
Real reader questions about these medications, each personally answered by our pharmacist:
Questions for your pharmacist
- Does my dose of Apixaban or Berotralstat need adjusting while I take them together?
- What symptoms should prompt me to call you or my prescriber right away?
- Does the timing of my doses matter for this combination?
- Is there a safer alternative to one of these medications for me?
References (1)
- Product Information: ORLADEYO® oral capsules, oral pellets, berotralstat oral capsules, oral pellets. BioCryst Pharmaceuticals Inc (per manufacturer), Durham, NC, 2025. DailyMed
Keep reading about Berotralstat
Keep reading about Apixaban
These medications also interact with supplements
Prescription drugs aren't the whole picture — herbal and dietary supplements can interact with them too. From the evidence-graded Natural Medicines database:
major · moderate · minor — check everything you take with our drug–supplement interaction checker.
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