Carbamazepine With Eliquis Concerns And Alternatives

In our latest question and answer, our pharmacist discusses the major interaction between Eliquis and carbamazepine and how to manage it.

Question

When I saw a hematologist, he wanted me to be on an anticoagulant like Eliquis (apixaban). However, he told me that I couldn't be on it with my mood stabilizer carbamazepine, so I have remained on warfarin where the dose can be adjusted. I would prefer to be on apixaban myself as I am terrible at getting my blood checked regularly. In your opinion, is it possible for me to be on apixaban with carbamazepine? I have generalized anxiety disorder and the bouts of anxiety I get can be quite severe. Would escitalopram be a good medication to replace the carbamazepine? The carbamazepine is hard on the liver and I would like to try something that doesn't have such bad effects on the body, as long as it works the same or hopefully better.

Asked by Jennifer On Jan 19, 2023

Answered by
Medical Content Reviewed By HelloPharmacist Staff

Published Jan 20, 2023
Last updated Jan 20, 2023

Key points

  • The interaction between Eliquis and carbamazepine is serious and it is generally recommended to avoid the combination as studies have reported that individuals taking carbamazepine and Eliquis together are at a higher risk for stroke and embolism compared to those not taking carbamazepine.
  • Alternative 'mood stabilizers', such as oxcarbazepine, lamotrigine, topiramate, and quetiapine do not have documented interactions with Eliquis but you should talk to your doctor about finding the best option for your
  • Additionally, there are other drug classes that can be effective for anxiety disorders, including SSRIs, like Lexapro, although these need to be used cautiously with drugs that increase bleeding risk.
  • Be sure to speak with your doctor about what the best drug options are for you.

Answer

Great question! Let's break it up into chunks. I'll first go over why your hematologist is cautioning against using Eliquis and carbamazepine together and then we'll get into what your options are.

Eliquis-Carbamazepine Interaction Details

The interaction between Eliquis and carbamazepine is a serious one, and most medical resources recommend avoiding the combination altogether.

Carbamazepine is a strong inducer of the CYP3A4 and P-glycoprotein enzymes. These enzymes play a crucial role in metabolizing and transporting drugs in the body. When carbamazepine is taken, it increases the activity of these enzymes, which can lead to a decrease in the serum concentration of Eliquis. This can make Eliquis less effective, putting you at risk of negative outcomes.

There have been a number of studies that have reported individuals taking carbamazepine and Eliquis together are more at risk for stroke and embolism when compared to individuals not taking carbamazepine (and drugs like it). One such study reported the following:

Higher risk for stroke/SE [systemic emboli] in patients with AF [atrial fibrillation] is associated with concurrent prescriptions of DOACs [like Eliquis] with phenytoin, carbamazepine, valproic acid, or levetiracetam.

Clin Pharmacol Ther . 2021 Dec;110(6):1526-1536.

Other studies have reported similar results, so this is an interaction to take seriously.

Now, it's important to note that carbamazepine also interacts with warfarin as studies show carbamazepine can decrease INR and the effects of vitamin K antagonists (e.g., warfarin). However, one of the positives of warfarin (if you want to look at it that way) is that the dose is very adjustable based on what your INR is. 

So, whereas carbamazepine will essentially just decrease how effective Eliquis is with little room for adjustments, warfarin can and generally will need to be adjusted if carbamazepine is used along with it.

You specifically asked, in my opinion, if you can in any way be on carbamazepine and Eliquis. I would say barring some reason why carbamazepine is the only therapy option for you, you should work with your doctor to find an alternative for the simple fact that studies show strong evidence that Eliquis will not be as effective. 

Alternatives To Carbamazepine

Providing alternatives to carbamazepine is a little tricky because I don't quite know exactly what you are using it for.

You are correct that it is classified as a 'mood stabilizer', but it is used for a wide variety of medical indications. Generally, when carbamazepine is used as a mood stabilizer, it is for the treatment of bipolar disorder (although they are sometimes used for certain anxiety disorders as well). Other 'mood stabilizers' used for bipolar include:

  • Oxcarbazepine
  • Lithium
  • Lamotrigine
  • Topiramate
  • Valproate
  • Quetiapine (not a mood stabilizer but is sometimes used for bipolar and anxiety disorders)

In terms of viable options to talk with your doctor about, I'll leave off lithium as that has some dosing challenges of its own and sometimes requires monitoring of blood lithium levels, something you've indicated you aren't too crazy about doing with warfarin.

Valproate, which is the active ingredient in several drugs, including Depakote does have an interaction with Eliquis, similar to carbamazepine. It is generally considered less clinically significant but does require monitoring regardless.

So, in regard to mood-stabilizing drugs that don't have documented interactions with Eliquis, we have left:

  • Oxcarbazepine
  • Lamotrigine
  • Topiramate
  • Quetiapine

These drugs aren't known to be hard on the liver, but it's still important to use them with caution if you have liver damage.

It's also important to note that while all of these drugs can be used, some of them don't have a lot of evidence to support their effectiveness. For example, Oxcarbazepine can be used as a mood stabilizer, but studies haven't shown that it's consistently effective in treating bipolar disorder.

In terms of what the best option for you is, I don't have all the details about your medical situation or history, so it's important to have a discussion with your doctor to determine the best mood-stabilizing drug for you. It's good to know at least that these options are considered safe to use with Eliquis and don't require lab testing.

Now, in your question, you mentioned you have generalized anxiety disorder and suggested Lexapro (escitalopram).

Lexapro is an SSRI, and all of these drugs come with a bleeding risk when combined with other blood-thinning drugs (like warfarin and Eliquis), but this is more something that you should be aware of and to be on the lookout for signs and symptoms of bleeding if you take it with Eliquis. They are often used together.

In fact, SSRIs are generally considered first-line treatment for generalized anxiety disorder because they have been well-studied and are effective for many people so Lexapro is absolutely a potential option for you.

Again, be sure to speak with your doctor about the best therapy options for your medical situation.

Final Words

Thanks so much for reaching out and I hope you found this helpful.

References

  • Effect of Enzyme-Inducing Antiseizure Medications on the Risk of Sub-Therapeutic Concentrations of Direct Oral Anticoagulants: A Retrospective Cohort Study, PubMed
  • Association Between Use of Pharmacokinetic-Interacting Drugs and Effectiveness and Safety of Direct Acting Oral Anticoagulants: Nested Case-Control Study, PubMed
  • Oxcarbazepine in bipolar disorder: a critical review of the literature, PubMed
  • Oxcarbazepine treatment of bipolar disorder, PubMed
  • The effect of carbamazepine on warfarin anticoagulation: a register-based nationwide cohort study involving the Swedish population, PubMed

About the Pharmacist

Dr. Brian Staiger, PharmD

Dr. Brian has been practicing pharmacy for over 13 years and has wide-ranging experiences in many different areas of the profession. From retail, clinical, program development, and administrative responsibilities, he's your knowledgeable and go-to source for all your pharmacy and medication-related questions! Dr. Brian Staiger also has herbalist training and educational certificates in the field of medical ethnobotany. Feel free to send him an email at Hello@HelloPharmacist.com! You can also connect with Dr. Brian Staiger on LinkedIn.

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