Key takeaways:
Xarelto (rivaroxaban) interactions include other blood thinners, nonsteroidal anti-inflammatory drugs (NSAIDs), and some antidepressants. It’s best to avoid taking Xarelto with these medications unless your prescriber OKs it.
Other Xarelto interactions include ketoconazole, Norvir (ritonavir), and Paxlovid (nirmatrelvir / ritonavir). These medications can increase Xarelto levels in the body, which can raise your risk of bleeding.
Alcohol and some over-the-counter supplements can also raise the risk of bleeding if you combine them with Xarelto.
Some anti-seizure medications and St. John’s wort supplements can make Xarelto less effective, which can raise your risk of blood clots.
Save on related medications
Xarelto (rivaroxaban) is a blood thinner medication that helps treat and prevent unwanted blood clots. It belongs to a class of blood thinners called direct-acting oral anticoagulants (DOACs).
Xarelto and other DOACs are generally considered safer than other blood thinners, such as warfarin (Coumadin, Jantoven). They’re less likely to cause bleeding-related side effects overall and don’t require a special diet. They also have fewer drug interactions to worry about. But fewer doesn’t mean none — there are still some interactions it’s good to be aware of if you’re taking Xarelto.
Xarelto interactions at a glance
Below is an overview of medications that may interact with Xarelto:
Other anticoagulants and antiplatelet medications (blood thinners)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Certain antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs)
Oral ketoconazole
Norvir (ritonavir)
Paxlovid (nirmatrelvir / ritonavir)
Alcohol
Rifampin (Rifadin)
Supplements that can raise your bleeding risk, such as turmeric, ginkgo biloba, and ginger
Pepto Bismol (bismuth subsalicylate)
Alka Seltzer (aspirin / citric acid / sodium bicarbonate)
Keep in mind, this list doesn’t include every possible Xarelto interaction. It’s best to have your healthcare team review your medication list to check for any interactions before starting Xarelto. It’s also a good idea to check with your prescriber or pharmacist before taking any over-the-counter (OTC) medications or supplements with Xarelto.
Let’s take a closer look at eight Xarelto interactions and their risks.
1. Other blood thinners
Because Xarelto is a blood-thinning medication, taking it with other prescription blood thinners can raise your risk of bleeding. This includes other DOACs, such as Eliquis (apixaban), and anticoagulants such as warfarin and Lovenox (enoxaparin). It also includes antiplatelet medications, such as Plavix (clopidogrel). Low-dose aspirin is also considered a blood thinner, but we’ll cover it in the next section.
In most cases, you’ll only take one blood thinner at a time. But in some situations, you may need to take more than one type of blood thinner. In this case, be sure to follow your prescriber’s instructions. And let them know if you notice any signs of mild bleeding, such as unusual bruising, frequent nosebleeds, or bleeding when brushing or flossing your teeth. These could be early signs that your blood isn’t clotting as well as it should.
If you notice blood in your urine or stool, you’re coughing or vomiting blood, or have a bruise that’s getting larger, seek emergency care. A more serious bleeding issue could be the cause.
2. NSAIDs
NSAIDs can also increase your bleeding risk. So it’s best to avoid combining them with blood thinners such as Xarelto.
Common OTC NSAIDs include ibuprofen (Advil, Motrin) and naproxen (Aleve). They’re also sometimes found in combination cold and flu medications, such as Advil Cold and Sinus (ibuprofen / pseudoephedrine). Even some medications for upset stomach, such as Pepto-Bismol and Alka Seltzer, may contain NSAIDs you’re not aware of.
Acetaminophen (Tylenol) is a safer OTC option for fever or pain if you’re taking Xarelto. You can also ask your pharmacist or prescriber for other NSAID alternatives that won’t increase your bleeding risk.
Good to know: Low-dose aspirin is an NSAID that’s OK to take with Xarelto. But you should only take a daily low-dose aspirin if your prescriber tells you to — it’s not recommended for everyone.
3. SSRIs and SNRIs
Some common antidepressants can also raise your risk of bleeding. The risk goes up if you take them with Xarelto. This includes SSRIs such as Zoloft (sertraline), Lexapro (escitalopram), and Prozac (fluoxetine). It also includes SNRIs, such as Effexor XR (venlafaxine ER) and Cymbalta (duloxetine).
Be sure to let your prescriber know you’re taking an antidepressant before starting Xarelto, or vice versa. In most cases, it’s still fine to take both medications. You’ll just need to keep a close eye out for signs or symptoms of bleeding, especially in the first few months of taking them together. But in some cases, your prescriber may prefer an antidepressant that doesn’t interact with Xarelto.
4. Ketoconazole
The oral antifungal medication ketoconazole can interact with Xarelto. It can raise Xarelto levels, which can increase your risk of a bleed. It’s best to avoid combining ketoconazole and Xarelto. So be sure to let your prescriber know you’re taking Xarelto if you need oral medication for a fungal infection. They can choose an option that doesn’t interact.
Good to know: This interaction only applies to oral ketoconazole tablets. Ketoconazole cream is fine to use for skin-related fungal infections if you’re taking Xarelto.
5. Norvir and Paxlovid
Norvir is a common prescription treatment for HIV. Ritonavir (the active ingredient in Norvir) is also an ingredient in Paxlovid, an antiviral medication that treats COVID-19. Ritonavir can prevent the body from breaking down Xarelto. This raises Xarelto levels in the body and increases the risk of side effects, including bleeding.
Taking Norvir, Paxlovid, or other medications that contain ritonavir with Xarelto isn’t recommended. Your prescriber may suggest a different blood thinner for you. Or they may choose a different antiviral medication, if that’s an option.
6. OTC supplements, such as St. John’s wort and turmeric
St. John’s wort is a popular herbal supplement that people take to help with depression. But it interacts with a lot of medications. And it can lower Xarelto levels in the body if they’re combined. This can make Xarelto less effective and put you at risk for blood clots.
It’s best to avoid taking St. John’s wort with Xarelto. Talk to your prescriber about safer options to help support your mental health.
Other supplements can raise your bleeding risk, especially if you combine them with a prescription blood thinner. Examples include ginkgo biloba, ginger, and turmeric. Omega-3, fish oil, and vitamin E supplements also carry this risk. Talk to your pharmacist or prescriber before taking any OTC supplements with Xarelto.
7. Certain antiseizure medications
Some antiseizure medications can interact with Xarelto. Dilantin (phenytoin) and Tegretol (carbamazepine) can increase the breakdown of Xarelto in the body. This can lower Xarelto levels and increase your risk of developing blood clots.
It’s best to avoid combining Xarelto with these medications. If you’re already taking one of these antiseizure medications, your prescriber will likely choose a different blood thinner for you. If you’re taking Xarelto and need to start an anti-seizure medication, they’ll likely choose one that’s less likely to have an interaction.
8. Alcohol
It’s best to avoid or limit alcohol while taking Xarelto. There’s no direct interaction between Xarelto and alcohol. But heavy alcohol use increases the risk of serious bleeding while taking Xarelto. A drink or two now and then shouldn’t be a problem. But keep in mind that even a moderate amount of alcohol can thin your blood and make bleeding more likely.
If you’re unsure how much alcohol is safe for you, it’s a good idea to check in with your healthcare team. They can also provide support to help you cut back on your drinking if you’re having trouble doing so on your own.
If you or someone you know struggles with substance use, help is available. Call SAMHSA’s National Helpline at 1-800-662-4357 to learn about resources in your area.
Do you need to avoid certain foods with Xarelto?
No, you don’t have to avoid any specific foods with Xarelto. Unlike warfarin, foods rich in vitamin K won’t interfere with how Xarelto works. But it’s a good idea to limit grapefruit and grapefruit juice while you’re taking Xarelto. Large amounts of grapefruit may raise Xarelto levels in the body.
There are some foods (mainly herbs and spices) that can raise your bleeding risk if you eat them in large amounts while taking Xarelto. Examples include garlic, grapeseed oil, and cayenne pepper. But these foods are typically fine in small amounts.
It’s also good to know that adults should take Xarelto doses of 15 mg or higher with food — preferably with your largest meal of the day. This helps your body absorb the medication better.
Can you drink prune juice while taking Xarelto?
Yes, it’s fine to drink prune juice while taking Xarelto. Prunes are high in vitamin K, so you need to monitor your intake of prunes and prune juice while taking warfarin. But vitamin K doesn’t affect Xarelto, so prune juice shouldn’t cause any problems.
Frequently asked questions
There isn’t an interaction between coffee and Xarelto. But coffee can interact with other medications. So it's a good idea to check in with your healthcare team to make sure coffee is safe for you based on your other medications and health conditions. And the FDA recommends limiting your caffeine intake to 400 mg or less per day.
Research shows that taking Xarelto in the evening leads to higher and longer-lasting levels of Xarelto in the bloodstream than morning doses. This makes taking it at night beneficial since studies show that the risk of dangerous blood clots is often higher early in the morning. So taking Xarelto in the evening helps ensure you’re protected from blood clots during the higher-risk early morning hours.
There isn’t an interaction between vitamin D and Xarelto, so it’s typically fine to take them together. But keep in mind that you shouldn’t take extra vitamin D on your own. Too much vitamin D can cause health problems. So you should only take vitamin D if your prescriber recommends it.
Yes, Xarelto can cause a skin rash, but this isn’t a common side effect. A Xarelto rash often involves itchy skin and small, red bumps that may be raised or flat. This type of rash is more common for children, but it can happen to anyone taking Xarelto. An antihistamine, such as loratadine (Claritin), can help reduce itchiness.
Keep in mind that a raised, itchy rash can also be a sign of an allergic reaction. So it’s best to contact your prescriber about any rash that appears while taking Xarelto. And seek emergency care if you’re also having trouble breathing or notice swelling of your mouth and throat.
There isn’t an interaction between coffee and Xarelto. But coffee can interact with other medications. So it's a good idea to check in with your healthcare team to make sure coffee is safe for you based on your other medications and health conditions. And the FDA recommends limiting your caffeine intake to 400 mg or less per day.
Research shows that taking Xarelto in the evening leads to higher and longer-lasting levels of Xarelto in the bloodstream than morning doses. This makes taking it at night beneficial since studies show that the risk of dangerous blood clots is often higher early in the morning. So taking Xarelto in the evening helps ensure you’re protected from blood clots during the higher-risk early morning hours.
There isn’t an interaction between vitamin D and Xarelto, so it’s typically fine to take them together. But keep in mind that you shouldn’t take extra vitamin D on your own. Too much vitamin D can cause health problems. So you should only take vitamin D if your prescriber recommends it.
Yes, Xarelto can cause a skin rash, but this isn’t a common side effect. A Xarelto rash often involves itchy skin and small, red bumps that may be raised or flat. This type of rash is more common for children, but it can happen to anyone taking Xarelto. An antihistamine, such as loratadine (Claritin), can help reduce itchiness.
Keep in mind that a raised, itchy rash can also be a sign of an allergic reaction. So it’s best to contact your prescriber about any rash that appears while taking Xarelto. And seek emergency care if you’re also having trouble breathing or notice swelling of your mouth and throat.
The bottom line
Xarelto (rivaroxaban) is a prescription blood thinner medication. Some Xarelto interactions can raise your risk of bleeding. This includes other blood thinners, nonsteroidal anti-inflammatory drugs (NSAIDs), and some antidepressants. Alcohol and some over-the-counter supplements may also increase your bleeding risk while taking Xarelto. You should avoid these combinations unless you have a healthcare professional’s OK.
Combining Xarelto with oral ketoconazole, ritonavir (Norvir), or Paxlovid (nirmatrelvir / ritonavir) can also raise your risk of bleeding. It’s best to avoid taking these medications together.
St. John’s wort supplements and certain anti-seizure medications can lower Xarelto levels in the body. This can make Xarelto less effective and raise your risk for blood clots. So these combinations aren’t recommended.
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References
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