Apixaban Interactions

St. John's wort strongly induces both CYP3A4 (apixaban's primary metabolizing enzyme) and P-glycoprotein (its efflux transporter). Co-use accelerates apixaban metabolism and clearance, lowering plasma concentrations and increasing the risk of stroke or thromboembolism.

Apixaban is a direct factor Xa inhibitor that increases bleeding risk on its own. Omega-3 fatty acids in fish oil reduce platelet aggregation in a dose-dependent way; a 2024 JAHA systematic review of 120,643 patients found omega-3 doses of approximately 3 g/day or less of EPA+DHA did not significantly raise bleeding risk, while higher doses (notably high-purity EPA in cardiovascular trials) showed a small absolute increase in bleeding events.