Tacrolimus and Apixaban: 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
Tacrolimus
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. Apixaban (Eliquis) is a blood thinner that helps prevent clots. Tacrolimus can slow down a transporter in your body (called P-gp) that normally helps clear apixaban out. When that transporter is blocked, more apixaban can stay in your blood, which may raise your risk of bleeding, like easy bruising, nosebleeds, or bleeding that is hard to stop.
I want to be clear that this concern is mostly theoretical right now, so please don't worry. Keep taking both medicines as prescribed, and let your pharmacist or doctor know you take them together so they can keep an eye on things.
Effect: Increased apixaban exposure with concurrent tacrolimus.
Mechanism: Tacrolimus inhibits P-glycoprotein (P-gp)-mediated efflux of apixaban (a P-gp substrate), reducing clearance and increasing plasma concentration/AUC. Neither agent is a prodrug; direction is a straightforward increase in anticoagulant exposure.
- Direction: Increased apixaban levels, greater bleeding risk (PD amplification).
- Onset: Unspecified.
- Evidence: Theoretical.
- Management: Consider avoiding coadministration. If required, monitor closely for bleeding (signs/symptoms, Hgb/Hct). Apixaban dose may need to be individualized by the care team.
What happens
Increased apixaban exposure
Interaction Deep Dive
Because apixaban is a P-gp substrate and tacrolimus acts as a P-gp inhibitor, taking the two together can raise apixaban concentrations and heighten the likelihood of bleeding, so avoiding this combination should be considered. Should the two need to be given together, treatment should be watched closely1.
Why it happens (mechanism)
Inhibition of P-gp-mediated efflux transport of apixaban
How to manage this interaction
The good news: your care team can manage this by tailoring your plan and watching you a bit more closely.
- Keep taking both exactly as prescribed unless your doctor or pharmacist tells you otherwise.
- Your team may decide to avoid this combination or, if you need both, watch you more carefully for bleeding.
- Your apixaban dose may need to be adjusted and individualized by your care team.
- Report right away: unusual bruising, nosebleeds, blood in urine or stool, black stools, pink or red urine, or bleeding that won't stop.
Management is individual — confirm any change with your pharmacist or prescriber.
Common questions
Can I take Tacrolimus and Apixaban together?
Tacrolimus can raise apixaban levels and increase bleeding risk, so tell your doctor or pharmacist you take both and watch for any signs of bleeding. Always confirm with your pharmacist or prescriber before making any change.
How serious is the Tacrolimus and Apixaban 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 Tacrolimus and Apixaban interaction managed?
The good news: your care team can manage this by tailoring your plan and watching you a bit more closely. Keep taking both exactly as prescribed unless your doctor or pharmacist tells you otherwise. Your team may decide to avoid this combination or, if you need both, watch you more carefully for bleeding. Your apixaban dose may need to be adjusted and individualized by your care team. Report right… Management is individual — always follow your own care team's guidance.
How strong is the evidence for this interaction?
The evidence is graded "theoretical". Predicted from the drugs' pharmacology; not yet confirmed in people.
From our Q&A
Real reader questions about these medications, each personally answered by our pharmacist:
Questions for your pharmacist
- Does my dose of Tacrolimus or Apixaban 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)
- 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.
Keep reading about Tacrolimus
Keep reading about Apixaban
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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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