Xarelto interactions with supplements

Xarelto (rivaroxaban) is a prescription blood thinner that can interact with several supplements, such as St. John’s wort (which may reduce its effectiveness), and Ginkgo biloba or turmeric (which may increase bleeding risk).

 If you’re taking Xarelto, it’s crucial to be aware of its interactions with other drugs and how they can impact its effectiveness or worsen side effects.

Xarelto supplement interactions

Like any medication, there are a few drugs that, if taken together, can cause an interaction. Xarelto’s most serious interactions often occur when it is mixed with certain supplements.

“Approximately one-third of the drug’s concentration in the body is removed by the kidneys through two transport proteins, P-gp and BCRP,” says Jerome Enad, MD, FAANA, ACSM-CEP  a board-certified orthopedic surgeon in Pensacola, Florida. “Another one-third is broken up in the liver (or metabolized) by cytochrome p-450 (CYP450) enzymes. Therefore, any supplement that affects the activity of these transport proteins or p-450 enzymes can potentially alter (increase or decrease) the effectiveness of Xarelto.”

Here’s a look at common Xarelto supplement interactions:

Supplement	Interactions/side effects
St. John’s wort	May reduce Xarelto’s effectiveness and increase risk of clots.
Ginkgo biloba	May increase bleeding risk
Turmeric	May increase bleeding risk

St. John’s wort

St. John’s wort (hypericum perforatum) is a flowering plant that many people use as a supplement to treat mild to moderate depression, menopausal symptoms, and minor cuts and burns. However, the U.S. Food and Drug Administration (FDA) has not approved nor regulated its use for these medical problems.

St. John’s wort can significantly reduce Xarelto’s effectiveness in your body and potentially lead to serious side effects. “St. John’s Wort is known to increase the function of a specific enzyme (CYP3A4) needed to break down Xarelto in the body,” says Stephanie Prozora, MD, a pediatric hematologist-oncologist and Assistant Professor of Pediatrics at Yale Pediatric Hematology & Oncology in New Haven, Connecticut. “When taken together, the increased function of CYP3A4 results in Xarelto being cleared faster than it should, making it less effective. Decreasing the effect of Xarelto may increase the risk of developing blood clots.”

Research supports Dr. Prozora’s claims. An open-label, non-randomized, sequential treatment interaction study found that taking St. John’s wort can reduce rivaroxaban’s effectiveness by activating the CYP3A4 enzyme. This enzyme breaks down the drug more rapidly than necessary and reduces its blood-thinning effect.

The reduction of Xarelto’s effectiveness can increase the risk of blood clots, which can lead to symptoms of deep vein thrombosis (DVT), such as:

• Swelling in one arm or leg
• Leg pain or tenderness that mimics a cramp or Charley horse
• Reddish or bluish skin discoloration
• Leg or arm warm to the touch

More serious complications of blood clots include pulmonary embolism (PE), which can cause symptoms like:

• Sudden shortness of breath
• Rapid heart rate
• Sharp, stabbing chest pain that worsens with deep breaths
• Unexplainable coughing—sometimes accompanied by bloody mucus

If you’re experiencing these symptoms, please seek immediate medical attention by calling 911 or getting taken to the nearest emergency room, as PE can be fatal.

Ginkgo biloba

Ginkgo biloba, also known as gingko, ginkgo, or maidenhair tree, is an over-the-counter supplement that some people claim helps with memory loss, eye problems, dementia, poor blood circulation, and tinnitus.

When taken with Xarelto, the natural supplement can cause adverse side effects. “Ginkgo inhibits CYP450, induces P-gp, and has anti-platelet activity,” Dr. Enad explains. “Overall, there is an increased risk of bleeding when ginkgo is taken with Xarelto.”

While medical experts advise against using Xarelto and Ginkgo biloba together, research suggests otherwise. One study found that taking either a single or repeated dose of Ginkgo biloba extract EGb 761 does not affect the blood levels of rivaroxaban. However, it’s best to go with your healthcare provider’s guidance on whether they believe taking this supplement with a blood thinner is safe for your health.

Turmeric

Turmeric, or Curcuma longa, is a flowering plant within the ginger family. Turmeric is a popular dietary supplement that many people believe can help treat medical conditions like depression, arthritis, gastrointestinal disorders, and allergies.

“Most patients needing a total knee replacement are taking some non-prescription substance on their own to help relieve their joint pain,” Dr. Enad says. “Although I ask my pre-op patients about any over-the-counter supplements, I specifically ask about turmeric. Turmeric has become a popular supplement to treat inflammation and arthritis, but patients are not aware that it has interactions that can increase bleeding when taken with Xarelto post-op.”

Research shows that turmeric’s active component, curcumin, has mild anticoagulant activity, which can interact with blood-thinning medications and increase the risk of bleeding.

Echinacea

Echinacea (purple cornflower) is a group of plants that contain many antioxidants that may support immune function and treat various medical problems. “Echinacea, a supplement used to reduce inflammation and boost the immune system, inhibits CYP450, thereby potentially increasing the concentration and effect of Xarelto,” Dr. Enad says.

Research backs this up, with one paper discovering that nine known species of the popular dietary supplement can potentially increase blood plasma concentration of rivaroxaban, as well as other blood-thinning agents like apixaban and edoxaban.

Other supplements that Xarelto may interact with include:

• Garlic

“I generally counsel my patients that Xarelto can interact with prescribed medications as well as many over-the-counter supplements,” Dr. Prozora says. “I advise all patients and their families to call our team prior to starting any new medications or supplements to avoid interactions.”

If you’re taking any supplements, please notify your healthcare provider before starting Xarelto to prevent mild to severe side effects.

Other Xarelto interactions

Supplements aren’t the only substances that can interact with Xarelto and potentially cause adverse effects. 

Some examples of drug interactions with the blood thinner include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn)
• Antiplatelet drugs: Aspirin, prasugrel (Effient), clopidogrel (Plavix), and ticagrelor (Brilinta)
• Other blood thinners: Warfarin (Jantoven) and heparin
• Selective-norepinephrine reuptake inhibitors (SNRIs): Duloxetine (Cymbalta) and desvenlafaxine (Pristiq)
• Selective serotonin reuptake inhibitors (SSRIs): Citalopram (Celexa), sertraline (Zoloft), and fluoxetine (Prozac)
• Certain antifungal drugs: Ketoconazole, itraconazole (Sporanox), levoketoconazole (Recorlev)
• Rifampin (Rifadin)
• Erythromycin (EryPed)
• Ritonavir (Norvir)

Other notable interactions with the blood-thinning medicine include:

• Cannabis products, including cannabidiol (CBD)
• Alcohol
• Foods like grapefruit 

There are also a few health-related Xarelto interactions: 

• Liver or kidney problems
• Triple-positive antiphospholipid syndrome (APS)
• Artificial heart valve  
• Active bleeding
• Planned surgery
• Pregnant or breastfeeding
• Allergic reaction to Xarelto or its ingredients

It’s essential to disclose any supplements, medications (prescription and over-the-counter), and medical conditions to your healthcare provider so they can assess whether taking Xarelto is safe.

How to minimize Xarelto interactions

There are several steps you can take to prevent or minimize Xarelto interactions. A good starting point is to ask your healthcare provider or pharmacist, but you can also plan to do the following:

• Immediately stop taking any supplements.
• Notify your healthcare provider if you drink alcohol or use cannabis products.
• Create a medication list that you can share with your healthcare team to ensure accurate and consistent care.
• Follow dosage instructions carefully.
• Pay attention to signs of potential side effects, such as excessive bruising, nosebleeds, or blood in urine or stool.
• Don’t stop treatment without consulting a healthcare provider.

When to talk to a healthcare provider about Xarelto interactions

Please note that this is not an exhaustive list of all the supplements and drugs that can interact with Xarelto. To minimize your risk of serious side effects, please disclose to your healthcare provider all supplements, medications, and medical conditions you are taking, to ensure there are no potential interactions.