Apixaban Interactions

St. John's wort strongly induces both CYP3A4 (apixaban's main metabolizing enzyme) and P-glycoprotein (its efflux transporter). Taken together, it speeds apixaban's breakdown and clearance, lowering blood levels and weakening clot protection, which raises the risk of stroke or thromboembolism.

Apixaban is a direct factor Xa inhibitor that raises bleeding risk on its own. Omega-3 fatty acids in fish oil have a mild antiplatelet effect that can theoretically add to that risk. A large 2024 systematic review and meta-analysis found that typical supplement-level omega-3 intake did not significantly raise bleeding risk, with only a small absolute increase seen at very high, prescription-strength doses. Standard fish oil is generally compatible with apixaban when the prescriber is aware, while high-dose omega-3 should be cleared with a clinician.