Rivaroxaban Interactions and Precautions
Introduction to Rivaroxaban Interactions
- Patients taking rivaroxaban should avoid St. John's wort and limit grapefruit juice to less than 240 mL daily, while rivaroxaban should always be taken with food to maximize absorption 1, 2
Food and Rivaroxaban Interactions
- Rivaroxaban should be taken with food, as this increases its bioavailability by 39% 2
- Food significantly increases rivaroxaban absorption, resulting in a 39% higher plasma concentration when taken with food 2
- The American Heart Association recommends taking rivaroxaban with meals to ensure proper absorption and consistent anticoagulant effect 2
Herbal Interactions with Rivaroxaban
- St. John's wort is strongly contraindicated as it significantly reduces rivaroxaban levels by inducing CYP3A4 and P-glycoprotein, potentially decreasing anticoagulant effect by up to 50% 1, 2
- The American College of Cardiology advises completely avoiding St. John's wort due to significant reduction in drug efficacy 1
Grapefruit Juice and Rivaroxaban Interactions
- Grapefruit juice should be limited to less than 240 mL daily as it inhibits CYP3A4 enzyme, potentially increasing rivaroxaban levels 1
Other Interactions and Precautions
- Other fruits such as pomegranate, mango, avocado, and papaya may alter rivaroxaban metabolism through various mechanisms and should be consumed with caution 1
- Herbal supplements with potential interactions, such as saffron and other herbs with antiplatelet effects (ginger, garlic), may increase bleeding risk and should be used with caution 1
- Patients with renal impairment are at higher risk of adverse effects from food-drug interactions due to altered drug clearance 3, 4
- Elderly patients may be more sensitive to changes in rivaroxaban levels caused by food interactions 5
- Concomitant use of NSAIDs or antiplatelet drugs further increases bleeding risk and should be avoided or used with extreme caution, according to the European Society of Cardiology 6