by Rajnish (“Raj”) Mago, MD (bio)
Question from a Member:
Do patients on serotonin agents like SSRIs or SNRIs need added monitoring if they are on non-warfarin blood thinners? My cardiologist colleague recommended that I check a CBC [complete blood count] every 6 months when I asked if there was any monitoring to be done for a patient on apixaban (Eliquis) and fluoxetine (Prozac).
I am not sure that that would be helpful since fluoxetine only reduces platelet aggregation, not platelet numbers.
Apixaban (brand name Eliquis®) belongs to the class of oral anticoagulants called direct Factor Xa inhibitors, which is a subcategory of the larger class called direct-acting oral anticoagulants (DOACs). (This is not a typo; the abbreviation is DOAC.)
Direct-acting oral anticoagulants are now being used in the majority of patients instead of warfarin. Their use is widespread in patients with atrial fibrillation, venous thrombosis, myocardial infarction, and so on. (I myself took apixaban for many months for the treatment of deep vein thrombosis in my leg that occurred after I fell and broke my foot many years ago.)
For a detailed discussion about what mental health clinicians should know about direct-acting oral anticoagulants and their use along with antidepressant medications, please see the following article on this website:
Direct-acting oral anticoagulants (DOACs) and antidepressants
Why our Member’s question is clinically very important
The question that our Member brought up is clinically very important for the following reasons:
1. Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and direct-acting oral anticoagulants (DOACs) are all used quite commonly.
2. Simultaneous treatment with both a serotonin reuptake inhibitor (SSRI or SNRI) and a direct-acting oral anticoagulant (DOAC) is associated with an increased risk of major bleeding according to a meta-analysis of studies (Weng and Lan, 2025).
What mental health clinicians should know about DOACs and antidepressants
Next, let’s look at the important things that mental health clinicians should know about direct-acting oral anticoagulants (DOACs) and their use along with antidepressants.
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