Xarelto: Interactions you should know about

Xarelto drug interactions overview

The following table shows some of the drugs that can interact with Xarelto:

This table does not include all drugs that may interact with Xarelto. For more information about some of these interactions, see the “Drug interaction details” section below.

Drug interaction details

Here’s a closer look at certain drug interactions of Xarelto.

Nonsteroidal anti-inflammatory drugs

It may not be safe to take Xarelto with NSAIDs. These are a type of pain reliever. People typically take NSAIDS to treat inflammation and pain.

Interaction result: Taking Xarelto in combination with an NSAID can increase the risk of bleeding.

Interaction explained: Xarelto works by blocking the action of factor Xa. (Factor Xa is a clotting factor, which is a substance that helps blood clot.) By blocking the action of factor Xa, Xarelto helps prevent blood clots from forming or becoming larger. This can increase your risk of bleeding.

NSAIDs can prevent platelets (a type of blood cell) from grouping together to form a blood clot. By affecting platelets, NSAIDs can also increase your risk of bleeding.

Therefore, taking Xarelto together with an NSAID can further increase your risk of bleeding.

Examples of NSAIDs: Below are a few NSAIDs that may interact with Xarelto:

• ibuprofen (Advil, Motrin)
• naproxen (Aleve, Naprosyn)
• magnesium salicylate (Doan’s)
• diclofenac (Voltaren)
• celecoxib (Celebrex, Elyxyb)

Steps you or your doctor may take: Keep in mind that many NSAIDs are available over the counter (OTC), meaning can purchase them without a prescription. It’s important to talk with your doctor or pharmacist before taking any OTC products with Xarelto. They can check whether the products include NSAIDs as ingredients.

If your doctor says that it’s safe to take an NSAID with Xarelto, tell them right away if you have symptoms of bleeding. Examples include coughing up blood, having unexplained bruising, and having bloody urine or stool. Your doctor can instruct you on what to do about this side effect.

Certain antibiotic drugs

Doctors may not prescribe Xarelto with certain antibiotic drugs. Antibiotics treat different types of bacterial infections.

Interaction result: The interaction between Xarelto and the antibiotic drug depends on the specific antibiotic.

Taking Xarelto with erythromycin (E.E.S., Ery-Tab, EryPed, others) could increase your risk of side effects from Xarelto. However, taking Xarelto with rifampin (Rifadin) could make Xarelto less effective than usual.

Interaction explained: Xarelto is broken down in the body by an enzyme called cytochrome P450 3A4 (CYP3A4). An enzyme is a type of protein.

Erythromycin slows down the activity of CYP3A4. This means that Xarelto may not break down in your body as quickly, which could increase the level of the drug in your system. The result may be a greater risk of side effects from Xarelto.

Rifampin, on the other hand, speeds up the activity of CYP3A4. This means that Xarelto may break down in your body more quickly, which could decrease the level of the medication in your system. As a result, Xarelto could be less effective than usual.

Steps you or your doctor may take: Before taking Xarelto, be sure to tell your doctor if you’re taking erythromycin or rifampin. They can recommend whether it’s safe to take either drug with Xarelto.

If your doctor prescribes an antibiotic during Xarelto treatment, it’s important that they know you’re taking Xarelto. They can advise you on whether it’s safe to take Xarelto with the specific antibiotic you’re prescribed.

Antiplatelet drugs

It may not be safe to take Xarelto with antiplatelet drugs. These drugs are used to help prevent blood clots from forming.

Interaction result: Taking Xarelto with an antiplatelet drug can increase the risk of bleeding.

Interaction explained: Xarelto works by blocking the action of a clotting factor called factor Xa. (Clotting factors are proteins that help your blood clot.) By blocking the action of this clotting factor, Xarelto helps prevent blood clots from forming or getting larger. This can increase your risk of bleeding.

Antiplatelet drugs work by preventing platelets (a type of blood cell) from sticking together to form a blood clot. By affecting this process, antiplatelet drugs can also increase your risk of bleeding.

As a result, taking Xarelto with antiplatelet drugs can increase your risk of bleeding further.

Examples of antiplatelet drugs: Here are examples of antiplatelet drugs that may interact with Xarelto:

• aspirin
• prasugrel (Effient)
• clopidogrel (Plavix)
• ticagrelor (Brilinta)

Steps you or your doctor may take: Before taking Xarelto, be sure your doctor knows if you’re taking an antiplatelet drug. They can advise you on whether it’s safe to take these medications together.

If your doctor tells you it’s safe to take an antiplatelet drug with Xarelto, watch for symptoms of bleeding. Tell your doctor right away if you cough up blood or have unexplained bruising, bloody urine, or bloody stool. They can tell you how to manage this side effect.

Interactions with other substances

Xarelto interactions are not limited to adverse effects with other drugs. Here are other possible substances that can interact with Xarelto.

Xarelto interactions with vitamins, herbs, and nutritional supplements

Before you start treatment with Xarelto, tell your doctor and pharmacist about any vitamins and supplements you take. Sharing this information may help prevent possible interactions.

Omega-3 fatty acids

Omega-3 fatty acids (“omega-3s”) may interact with Xarelto. Some people take omega-3 supplements to help lower blood pressure and levels of triglycerides. Taking an omega-3s with Xarelto may worsen Xarelto’s risk of bleeding.

Note: Healthful foods that contain omega-3 fatty acids (salmon and other fatty fish, for example) have not been reported to interact with Xarelto. In part, this may be because the amount of natural omega-3s in food is typically much lower than what is contained in many supplements.

Herbs

An herb called St. John’s wort may interact with Xarelto. Some people take St. John’s wort to treat depression. Taking this herbal supplement may make Xarelto less effective. Your doctor may advise you to avoid taking St. John’s wort during Xarelto treatment.

Xarelto interactions with food

Eating grapefruit or drinking grapefruit juice while taking Xarelto could raise the level of the medication in your body. A higher level of Xarelto could increase your risk of side effects from the drug. Your doctor may advise you to avoid eating grapefruit or drinking grapefruit juice during Xarelto treatment.

If you have other questions about what not to eat or drink while taking Xarelto, talk with your doctor or pharmacist.

Xarelto and alcohol

There is no known interaction between Xarelto and alcohol.

However, both Xarelto and alcohol can prevent blood from clotting. This can increase your risk of bleeding. As a result, consuming alcohol during Xarelto treatment could increase your risk of bleeding further.

If you drink alcohol, talk with your doctor. They can tell you whether there’s a safe amount of alcohol to drink while taking Xarelto.

Xarelto and health-related interactions

Certain medical conditions and other factors may increase the risk of interactions with Xarelto. Before you take Xarelto, be sure to talk with your doctor about your health history. Xarelto may not be the right treatment option for you if you have certain medical conditions or other factors affecting your health.

Health conditions or factors that might interact with Xarelto include the following:

Triple-positive antiphospholipid syndrome: Doctors may not prescribe Xarelto for people with triple-positive antiphospholipid syndrome (APS). This condition causes blood clots. Xarelto can increase the risk of blood clots in people with APS. Therefore, if you have triple-positive APS, your doctor will likely prescribe a treatment other than Xarelto.

Liver problems: If you have a severe liver problem, your doctor may not prescribe Xarelto. Examples of severe liver problems include hepatitis and cirrhosis. It is unknown whether Xarelto is safe for people with severe liver problems. If you have a problem with your liver, your doctor may prescribe a different treatment.

Kidney problems: Before taking Xarelto, be sure your doctor knows whether you have a kidney problem. Your risk of side effects with the medication may increase if your kidneys do not work as well as they should.

If you have a kidney problem, your doctor may prescribe a different treatment. Or they may prescribe a lower dosage of Xarelto than usual.

Artificial heart valve: Doctors are not likely to prescribe Xarelto for people who have an artificial heart valve. The drug has not been studied in people who have one. So it is unknown for certain whether the drug is safe to take in this case. If you have an artificial heart valve, your doctor can recommend a different treatment for your condition.

Planned surgery: If you plan to have surgery while taking Xarelto, talk with your doctor. They may have you stop taking the drug at least 1 day before the procedure. This is because having surgery while taking Xarelto could increase your risk of bleeding. Stopping use of the drug before the procedure could reduce this risk. Your doctor can advise you on what to do if you have a surgery planned during Xarelto treatment.

Active bleeding: Doctors typically will not prescribe Xarelto if you have active bleeding, such as a bleeding ulcer. For details, see the “When to avoid Xarelto” section above.

Pregnancy: It is unknown for certain whether Xarelto is safe to take during pregnancy. It has been reported that there is potential for pregnancy-related bleeding and emergent delivery (birth unexpectedly soon after contractions begin) with Xarelto. For details about taking Xarelto during pregnancy, talk with your doctor.

Breastfeeding: Xarelto passes into breast milk. However, it is unknown whether the drug causes side effects in a breastfed child. If you’re breastfeeding or considering it, talk with your doctor. They can review the potential risks and benefits of the drug with you.

Allergic reaction: If you’ve had an allergic reaction to Xarelto or any of its ingredients, your doctor will likely not prescribe this drug. To learn more, see the “When to avoid Xarelto” section above.

Xarelto and vaccines

No specific interactions have been reported between Xarelto and vaccines. If you have questions about getting vaccines during Xarelto treatment, talk with your doctor or pharmacist.

Xarelto and lab tests

Lab tests have not been reported to interact with Xarelto. Your doctor or pharmacist can give you additional information about having lab tests during Xarelto treatment.

When to avoid Xarelto

Sometimes, a factor or condition could prevent your doctor from prescribing Xarelto due to the risk of harm. This is known as a contraindication. The contraindications of Xarelto include:

Having active bleeding

Doctors typically will not prescribe Xarelto if you have active bleeding. (Active bleeding refers to current bleeding, such as a bleeding ulcer.) Taking Xarelto while you have active bleeding could worsen it. If you have active bleeding, your doctor can advise you on other treatments that may be better for your condition.

Having had an allergic reaction to Xarelto or any of its ingredients

If you have had an allergic reaction to Xarelto or any of its ingredients, your doctor will likely not prescribe Xarelto. Taking the drug could cause another allergic reaction. You can ask your doctor about other treatments that may be better choices for you.

Frequently asked questions about Xarelto interactions

Preventing interactions

You can take certain steps to help prevent interactions with Xarelto. Your doctor and pharmacist are key resources, so reach out to them before starting treatment.

For example, consider creating a medication list of all prescription and over-the-counter (OTC) medications you take and show this to them before starting Xarelto.

Also tell them about any supplements, herbs, and vitamins you take, and whether you drink alcohol.

It is also important to read the Xarelto prescription drug label and prescribing information that may come with the medication. The label may have colored stickers that mention an interaction. And other paperwork, sometimes called the medication guide or patient package insert, may contain details about possible interactions.

You can also help prevent interactions with Xarelto by taking the medication exactly as your doctor prescribes.

Summary

Xarelto (rivaroxaban), a brand-name anticoagulant used to treat and prevent blood clots, can cause various interactions. It can interact significantly with several drug classes, most notably nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, antiplatelet drugs like aspirin, and certain antidepressants (SSRIs and SNRIs), all of which can dangerously increase risk of bleeding. Specific antibiotics and seizure medications can either make Xarelto less effective or increase its side effects by altering how the body processes the drug.

Beyond medications, while there is no apparent Xarelto interaction with alcohol, consuming alcohol while taking Xarelto can increase bleeding risks, and supplements like St. John’s wort should be avoided. Xarelto also has FDA boxed warnings regarding the risk of spinal blood clots during certain medical procedures and increased danger of stroke if the medication is discontinued without supervision by a doctor.

This article is a summary of Xarelto’s potential interactions with certain drugs, other substances, and health conditions. For more details, see Xarelto’s prescribing information or talk with your doctor.