Managing Direct Oral Anticoagulants in Patients With Antiepileptic Medication

Current guidance recommends avoiding concomitant use of direct-acting oral anticoagulants and enzyme-inducing antiepileptic drugs because of theoretical drug interactions potentially leading to subtherapeutic drug concentrations and treatment failure. We describe a case documenting a significant interaction between phenobarbital and rivaroxaban, and then apixaban. This case illustrates and supports the concerns regarding concomitant use of these medications. Additionally, in this case the interaction was managed with concentration-guided dosing of apixaban, suggesting this approach may represent a feasible strategy for managing patients requiring treatment with direct-acting oral anticoagulants and enzyme-inducing antiepileptic drugs.