Cephalexin and Apixaban Interaction

Pharmacological Considerations

Apixaban is a direct oral anticoagulant that is primarily metabolized via the liver through cytochrome P450 3A4-dependent pathways, with approximately 27% eliminated through renal excretion, according to the American Heart Association 1
Apixaban is a substrate for both CYP3A4 enzymes and P-glycoprotein (P-gp)/BCRP transporters, making it susceptible to interactions with drugs that affect these pathways, as stated by the European Society of Cardiology [1, 2 is ignored in favor of 1]

Severe renal impairment (CrCl <15 mL/min) may increase bleeding risk, and apixaban should be used with caution in these patients, as recommended by the National Comprehensive Cancer Network 3, 4
Hepatic impairment may affect apixaban metabolism, and patients with liver disease may require closer monitoring, according to the American College of Cardiology 1
Concomitant use of other medications that affect hemostasis (e.g., NSAIDs, antiplatelet drugs) may increase bleeding risk, as warned by the American Academy of Otolaryngology-Head and Neck Surgery 5

For patients undergoing invasive procedures, the European Society of Anaesthesiology recommends following standard protocols for temporary discontinuation of apixaban based on bleeding risk of the procedure 6
For low bleeding risk procedures, apixaban can be discontinued the morning of the day before the procedure (if twice daily regimen) or two days before (if once daily evening regimen), as suggested by the European Society of Anaesthesiology 6
For high bleeding risk procedures, apixaban should be discontinued three days before the procedure, according to the European Society of Anaesthesiology 6