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“Direct-acting oral anticoagulants (DOACs) are mainly affected by medications strongly affecting the permeability glycoprotein (P-gp) and, to a lesser extent, strong CYP3A4 inhibitors/inducers. Strong inhibitors/inducers of CYP2C9, CYP3A4, and CYP1A2 may affect warfarin in drug–drug interactions. Strong inducers of CYP3A4 or P-gp should be avoided in all patients taking DOACs, whereas simultaneous use of strong CYP3A4 and P-gp inhibitors should be avoided in patients taking apixaban and rivaroxaban. Dabigatran and edoxaban are affected by P-gp modulation. Concomitant antiplatelet/anticoagulant use confers an additive risk for bleeding.
Minimizing the duration of concomitant anticoagulant/antiplatelet therapy, as indicated by evidence-based clinical guidelines, is the best way to reduce the risk of bleeding.“