1. Direct oral anticoagulants (DOAC) are being increasingly use. Rivaroxaban is metabolized via CYP3A4, with in vitro studies supporting the involvement of P-glycoprotein as the responsible active transporter in renal secretion of rivaroxaban.
2. Antifungal imidazole derivatives have been shown to demonstrate significant inhibition of CYP450. Miconazole, a combined p-glycoprotein and strong CYP3A4-inhibitor, can potentially cause significant drug interaction and increased rivaroxaban concentration.
3. Interference of topical miconazole with warfarin has been reported, but not with DOAC. Systemic absorption appears to be enhanced when miconazole is applied under occlusion on large surface, close to mucous membranes or in cases of intertrigo skin lesions.
4. In summary, the use of topical miconazole may have significant drug interaction with rivaroxaban resulting in adverse event from over-anticoagulation.
The prescribing clinician should be aware of this possible interaction and exercise close monitoring if simultaneous use is indicated.
The interaction has been highlighted previously as a short communication (http://journals.sagepub.com/doi/pdf/10.1177/201010581502400209), and it was cited in Reactions journal as the first report of such interaction (https://link.springer.com/article/10.1007/s40278-015-4084-y).
Full text:
KG Lee, DL Jennifer. Increased bleeding tendency from interaction between rivaroxaban and topical miconazole: Case report. Proceedings of Singapore Healthcare 2015; 24:121-2.
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