MajorDirect oral anticoagulants (factor Xa inhibitors)×Antituberculous antibiotic
Updated · Methodology
Mechanism
Rifampicin is the strongest clinical inducer of CYP3A4 and P-glycoprotein. Apixaban levels fall by 54%, anticoagulation lost. FDA recommends avoiding the combination.
Symptoms
Ischemic stroke or recurrent VTE on apparently active apixaban. Lab: low anti-Xa level.
Management
The combination is avoided. In a patient on rifampicin, the apixaban SmPC does not recommend apixaban for treating deep vein thrombosis or pulmonary embolism, because efficacy may be compromised. For stroke prevention in atrial fibrillation it allows use with caution, while the FDA label says to avoid the pair for any indication. Apixaban is usually replaced for the rifampicin course by a parenteral anticoagulant such as a low-molecular-weight heparin. Warfarin is awkward here: per the rifampicin SmPC, S-warfarin exposure falls by 74%. The warfarin dose is then titrated under frequent INR checks and reduced again after rifampicin stops.
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Sources
- FDA: Eliquis (apixaban) prescribing information (2021)– ; DailyMed setid e9481622-7cc6-418a-acb6-c5450daae9b0
- AEMPS: Ficha técnica de Eliquis 5 mg comprimidos recubiertos con película (apixabán) (2026)– AEMPS, CIMA (texto EMA), nº registro 111691009, secciones 4.4 y 4.5
- AEMPS: Ficha técnica de Rifaldin 300 mg cápsulas (rifampicina) (2026)– AEMPS, CIMA, nº registro 46029, secciones 4.3 y 4.5