Apixaban and Fluvoxamine: 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
Fluvoxamine
No brand names on recordApixaban
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. Apixaban (Eliquis) is a blood thinner that helps prevent dangerous clots. Fluvoxamine can slow down the natural process your body uses to clear apixaban out of your system. When that clearing slows down, more apixaban can build up in your blood.
More apixaban means a stronger blood-thinning effect, which can raise your chance of bleeding, things like easy bruising, nosebleeds, or bleeding that is slow to stop. The good news is this is very manageable. Your care team can watch you more closely and adjust things if needed. Keep taking both medicines as prescribed and let your pharmacist or doctor know if you notice unusual bleeding or bruising.
Effect: Increased apixaban exposure and elevated bleeding risk.
Mechanism: Fluvoxamine inhibits CYP3A4-mediated metabolism and P-gp-mediated efflux of apixaban (a dual substrate), reducing clearance and raising serum concentrations. Neither agent is a prodrug, so the effect is a straightforward increase in apixaban activity.
- Magnitude: For a comparable dual P-gp/moderate CYP3A4 inhibitor (diltiazem), apixaban Cmax rose ~31% and AUC ~39%.
- Evidence: Probable; severity major.
- Management: Use with caution if coadministration is required. Monitor for signs of bleeding; dose may need individualization by the care team.
What happens
Increased apixaban exposure and increased risk of bleeding
Interaction Deep Dive
Because apixaban is a substrate of both P-gp and CYP3A42, giving it alongside an agent that inhibits both P-gp and moderately inhibits CYP3A4 can raise apixaban serum levels 5 and heighten the likelihood of bleeding 4. One pharmacokinetic investigation found that when apixaban was given together with diltiazem, a dual P-gp and moderate CYP3A4 inhibitor, its Cmax rose by 31% and its AUC by 39% 5. Should the two need to be used together, exercise caution 31.
Why it happens (mechanism)
Inhibition of CYP3A4-mediated apixaban metabolism; inhibition of P-gp-mediated efflux transport of apixaban
How to manage this interaction
This can be managed safely. Your care team knows apixaban levels can run higher when combined with fluvoxamine, and they can plan around it.
- Keep taking both medicines exactly as prescribed unless your prescriber tells you otherwise.
- Your team may monitor you more closely, and your apixaban dose may need to be adjusted and individualized by them.
- Watch for signs of bleeding: unusual bruising, nosebleeds, pink or red urine, black stools, or bleeding that won't stop.
- Report any of these promptly to your pharmacist or doctor.
Do not start or stop either drug on your own, talk with your care team first.
Management is individual — confirm any change with your pharmacist or prescriber.
Literature reports
2 reports — tap to read
a) In a retrospective observational analysis (N=426), the use of an agent that inhibits both P-gp and CYP3A4 moderately notably raised the risk of bleeding among patients receiving apixaban or rivaroxaban for atrial fibrillation. Bleeding, characterized as the combined total of major, clinically relevant non-major, and minor bleeding, was seen in 26.4% of patients in the interacting agent group compared with 18.4% in the propensity-matched control group (HR, 1.8; 95% CI, 1.19 to 2.73). The interacting agents were diltiazem (68.1%), amiodarone (26.8%), verapamil (5.7%), dronedarone (2.3%), and multiple agents (2.8%); none of the patients were given concurrent erythromycin. When the individual drug interactions were assessed separately, no significant differences in bleeding rates were found, and the effects of renal dysfunction, the particular inhibitor, or the particular anticoagulant were not assessed 4.
b) Giving diltiazem, an agent that inhibits both P-gp and CYP3A4 moderately, together with apixaban raised apixaban Cmax by 31% and AUC by 39% relative to apixaban given by itself. Oral apixaban 10 mg was given 8 days after starting diltiazem 360 mg once daily in 18 subjects 5.
Common questions
Can I take Apixaban and Fluvoxamine together?
Combining fluvoxamine with apixaban can raise apixaban levels and increase bleeding risk, so use both as prescribed and have your care team monitor you and adjust the dose if needed. Always confirm with your pharmacist or prescriber before making any change.
How serious is the Apixaban and Fluvoxamine 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 Fluvoxamine interaction managed?
This can be managed safely. Your care team knows apixaban levels can run higher when combined with fluvoxamine, and they can plan around it. Keep taking both medicines exactly as prescribed unless your prescriber tells you otherwise. Your team may monitor you more closely, and your apixaban dose may need to be adjusted and individualized by them. Watch for signs of bleeding: unusual bruising, nose… 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 Fluvoxamine 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 (5)
- Burnett AE, Mahan CE, Vazquez SR, et al: Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis 2016; 41(1):206-232. PubMed
- Product Information: ELIQUIS(R) oral tablets, apixaban oral tablets. Bristol-Myers Squibb Company (per FDA), Princeton, NJ, 2019. DailyMed
- Steffel J, Collins R, Antz M, et al: 2021 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Europace 2021; 23(10):1612-1676.
- Hanigan S, Das J, Pogue K, et al: The real world use of combined P-glycoprotein and moderate CYP3A4 inhibitors with rivaroxaban or apixaban increases bleeding. J Thromb Thrombolysis 2020; 49(4):636-643. PubMed
- Frost CE, Byon W, Song Y, et al: Effect of ketoconazole and diltiazem on the pharmacokinetics of apixaban, an oral direct factor Xa inhibitor. Br J Clin Pharmacol 2015; 79(5):838-846.
Keep reading about Fluvoxamine
Keep reading about Apixaban
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