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Mar PL, Gopinathannair R, Gengler BE, Chung MK, Perez A, Dukes J, Ezekowitz MD, Lakkireddy D, Lip GYH, Miletello M, Noseworthy PA, Reiffel J, Tisdale JE, Olshansky B. Drug Interactions Affecting Oral Anticoagulant Use. Circ Arrhythm Electrophysiol 2022; 15:e007956. [PMID: 35622425 PMCID: PMC9308105 DOI: 10.1161/circep.121.007956] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Oral anticoagulants (OACs) are medications commonly used in patients with atrial fibrillation and other cardiovascular conditions. Both warfarin and direct oral anticoagulants are susceptible to drug-drug interactions (DDIs). DDIs are an important cause of adverse drug reactions and exact a large toll on the health care system. DDI for warfarin mainly involve moderate to strong inhibitors/inducers of cytochrome P450 (CYP) 2C9, which is responsible for the elimination of the more potent S-isomer of warfarin. However, inhibitor/inducers of CYP3A4 and CYP1A2 may also cause DDI with warfarin. Recognition of these precipitating agents along with increased frequency of monitoring when these agents are initiated or discontinued will minimize the impact of warfarin DDI. Direct oral anticoagulants are mainly affected by medications strongly affecting the permeability glycoprotein (P-gp), and to a lesser extent, strong CYP3A4 inhibitors/inducers. Dabigatran and edoxaban are affected by P-gp modulation. Strong inducers of CYP3A4 or P-gp should be avoided in all patients taking direct oral anticoagulant unless previously proven to be otherwise safe. Simultaneous strong CYP3A4 and P-gp inhibitors should be avoided in patients taking apixaban and rivaroxaban. Concomitant antiplatelet/anticoagulant use confers additive risk for bleeding, but their combination is unavoidable in many cases. Minimizing duration of concomitant anticoagulant/antiplatelet therapy as indicated by evidence-based clinical guidelines is the best way to reduce the risk of bleeding.
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Affiliation(s)
- Philip L Mar
- Division of Cardiology, Department of Medicine, St. Louis University, MO (P.L.M., A.P.)
| | | | - Brooke E Gengler
- Department of Pharmacy, Saint Louis University Hospital, MO (B.E.G.)
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute (M.K.C.)
| | - Arturo Perez
- Division of Cardiology, Department of Medicine, St. Louis University, MO (P.L.M., A.P.)
| | | | - Michael D Ezekowitz
- Lankenau Heart Institute, Bryn Mawr Hospital & Sidney Kimmel Medical College, Wynnewood, PA (M.D.E.)
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.).,Department of Clinical Medicine, Aalborg, Denmark (G.Y.H.L.)
| | | | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.N.)
| | - James Reiffel
- Division of Cardiology, Department of Medicine, Columbia University, New York (J.R.)
| | - James E Tisdale
- College of Pharmacy, Purdue University (J.E.T.).,School of Medicine, Indiana University, Indianapolis (J.E.T.)
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City (B.O.)
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Palacios-Zabalza I, Bustos-Martínez M, Peral-Aguirregoitia J, Martínez-Bengoechea MJ, Aguirre Gomez C. Probable interaction between acenocoumarol and levofloxacin: a case series. J Clin Pharm Ther 2015; 40:693-5. [DOI: 10.1111/jcpt.12324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 08/20/2015] [Indexed: 11/30/2022]
Affiliation(s)
| | - M. Bustos-Martínez
- Department of Pharmacy; Galdakao- Usansolo Hospital; Galdakao Bizkaia Spain
| | | | | | - C. Aguirre Gomez
- Basque Unit of Pharmacovigilance; Galdakao- Usansolo Hospital; Galdakao Bizkaia Spain
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