What food should be avoided with Xarelto? (3+ interactions)

In this article, we will discuss the different types of food which should be avoided while taking Xarelto. Additionally, we will also discuss the precautionary measures and effective ways of using Xarelto.

What food should be avoided with Xarelto? 

You should avoid eating foods and supplements such as St John’s wort, grapefruit, oats, ginko, Arabian coffee, cinnamon, saffron, turmeric, ginger, garlic, fish oil, and herbal medications. These foods and supplements, if taken in a higher amount, can increase the plasma concentration of Xarelto and increase the risk of bleeding. (1)

Xarelto (rivaroxaban) is an anticoagulant which helps prevent clot formation by thinning the blood. Xarelto is used as a prophylaxis during orthopaedic surgery, in preventing thromboembolism (clot that blocks blood vessels), and to prevent stroke in patients with cardiac arrhythmia, atrial fibrillation and deep venous thromboembolism. It is important to follow the instructions given by your physician to avoid the risk of bleeding. (2)

If you notice any uncontrolled bleeding, bruising, headache, dizziness, or altered mental status, seek medical help immediately. 

What does the research suggest? 

Research studies have shown that food or herbal supplements which inhibit or induce enzyme CYP3A4 or P-glycoprotein may interfere with the action of direct oral anticoagulants such as Xarelto. (3)

Herbal supplements such as St John’s wort are potent inducers of P-glycoprotein (P-gp) and CYP3A4 enzyme. As Xarelto is metabolized by these enzymes, an increase in CYP3A4 and P-gp can increase the elimination of the drug, which can lead to a reduction in its concentration. Rivaroxaban can be taken with food or without food. When taken with food, the effectiveness of Xarelto increases due to its improved bioavailability. (3)

An 80-year-old man who was being treated with dabigatran, a direct oral anticoagulant (DOAC), experienced fatal bleeding after consuming a boiled mixture of ginger and cinnamon twice daily for 3 days. As cinnamon and ginger exhibit antiplatelet activity, taken with Xarelto causes a synergistic action and increases the risk of bleeding when taken concomitantly, along with all DOACs, including Xarelto. (1)

What are the foods, drinks and herbs that interact with Xarelto? 

Some foods, drinks and herbs can increase or decrease the plasma concentration of the drug in the system; here are some foods, drinks and herbs that can interact with Xarelto along with their mechanism. 

Oats: Oats inhibit P-glycoprotein, which helps in the metabolism and elimination of Xarelto, and inhibition of this enzyme can increase the plasma concentration of all DOACs. 

Ginkgo: Ginkgo biloba contains antioxidants, which are helpful in reducing inflammation and is used in the treatment of blood and memory disorders. Ginkgo inhibits CYP450 enzymes and P-glycoprotein, which increase the plasma concentration of all DOACs. 

Cinnamon and ginger: Cinnamon and ginger have antiplatelet activity and can increase the risk of bleeding when used concomitantly with DOACs. 

Saffron: Saffron inhibits CYP450, 3A4, 3A5, 3A7, 2B6 and P-glycoprotein and increases the concentration of all DOACs. 

Turmeric: Turmeric has the ability to inhibit CYP450 enzymes, P-gp and also exhibits antiplatelet activity, which can enhance the anticoagulant properties and increase the risk of bleeding. 

Grapefruit juice: Grapefruit inhibits CYP3A4 and P-gp, which increases the plasma concentration of all DOACs.  

Alcohol: Alcohol does not alter the action of Xarelto. However, an excess amount of alcohol damages the liver, which can affect the metabolism of Xarelto. 

Herbal supplements: Supplements such as ginkgo, St John’s wort, etc., can act on the enzymes which metabolise Xarelto and fluctuate the levels of Xarelto in the system. 

Green tea: Green tea is prepared from dried leaves of Camellia sinensis, which possess antiplatelet activity and can increase the blood-thinning action of Xarelto. 

Fish oil: Fish oil is known to have anticoagulant activity, which can increase the risk of bleeding when used concomitantly with DOACs.

How to use Xarelto safely and effectively? 

Using Xarelto safely and effectively involves following a few steps: 

• Always take the dose of Xarelto as prescribed by your physician. 
• Do not change or stop taking the dose of Xarelto without consulting your physician. 
• Attended all scheduled follow-ups to ensure proper assessment of your treatment. 
• Cold medications, antidepressants (Sertraline, fluoxetine), NSAIDs, herbal supplements, etc., can interact with Xarelto and can increase the risk of bleeding. Make sure you discuss with your physician about the possible interaction between the drugs. 
• The use of Xarelto comes with a risk of bleeding. Look out for any bruises and avoid activities which can put you at risk of bleeding. 
• Consult your physician if you notice any unwanted changes while on Xarelto therapy. 
• Inform your doctor about your anticoagulant therapy if you are undergoing any invasive procedure, including dental surgery. 

What are the possible adverse effects of Xarelto-food interaction? 

Xarelto has shown increased bioavailabilty when it is taken with food than taken empty stomach. However, there are some foods, drinks and herbal supplements which should be avoided in order to minimise the risk of bleeding. The possible adverse effects of Xarelto-food interactions are as follows: (2,4)

• Increased bleeding risk
• Bruising
• Skin haemorrhage
• Bleeding per rectum/blood in stools
• GI bleeding
• Intracranial bleeding
• Hemothorax
• Stroke 
• Leg swelling
• Headache
• Weakness

In my experience

As per my knowledge, Xarelto has less food-drug interaction compared to warfarin. However, there are a few foods and drinks that should be avoided while consuming anticoagulants to avoid the risk of bleeding and its complications. Always consult a doctor before taking any OTC medication or herbal supplements to rule out the risk, and have knowledge about the foods that may interact with Xarelto.

It is essential to consult a healthcare physician if you are experiencing any unwanted side effects. I recommend you seek immediate medical help if you notice too much bruising or increased bleeding to avoid further complications. 

References