Drug-drug interaction between dexamethasone and direct-acting oral anticoagulants: a nested case-control study in the National COVID Cohort Collaborative (N3C)

BMJ Open. 2022 Dec 29;12(12):e066846. doi: 10.1136/bmjopen-2022-066846.


Objective: The goal of this work is to evaluate if there is an increase in the risk of thromboembolic events (TEEs) due to concomitant exposure to dexamethasone and apixaban or rivaroxaban. Direct oral anticoagulants (DOACs), as well as corticosteroid dexamethasone, are commonly used to treat individuals hospitalised with COVID-19. Dexamethasone induces cytochrome P450-3A4 enzyme that also metabolises DOACs apixaban and rivaroxaban. This raises a concern about possible interaction between dexamethasone and DOACs that may reduce the efficacy of the DOACs and result in an increased risk of TEE.

Design: We used nested case-control study design.

Setting: This study was conducted in the National COVID Cohort Collaborative (N3C), the largest electronic health records repository for COVID-19 in the USA.

Participants: Study participants were adults over 18 years who were exposed to a DOAC for 10 or more consecutive days. Exposure to dexamethasone was at least 5 or more consecutive days.

Primary and secondary outcome measures: Our primary exposure variable was concomitant exposure to dexamethasone for 5 or more days after exposure to either rivaroxaban or apixaban for 5 or more consecutive days. We used McNemar's Χ2 test and adjusted logistic regression to evaluate association between concomitant use of dexamethasone with either apixaban or rivaroxaban.

Results: McNemar's Χ2 test did not find a discernible association of TEE in patients concomitantly exposed to dexamethasone and a DOAC (χ2=0.5, df=1, p=0.48). In addition, a conditional logistic regression model did not find an increase in the risk of TEE (adjusted OR 1.15, 95% CI 0.32 to 4.18).

Conclusion: This nested case-control study did not find evidence of an association between concomitant exposure to dexamethasone and a DOAC with an increase in risk of TEE. Due to small sample size, an association cannot be completely ruled out.

Keywords: Anticoagulation; BIOTECHNOLOGY & BIOINFORMATICS; CLINICAL PHARMACOLOGY; COVID-19; Health informatics; Thromboembolism.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Administration, Oral
  • Adult
  • Anticoagulants / adverse effects
  • Atrial Fibrillation* / drug therapy
  • COVID-19 Drug Treatment
  • COVID-19*
  • Case-Control Studies
  • Dabigatran / therapeutic use
  • Dexamethasone / adverse effects
  • Drug Interactions
  • Factor Xa Inhibitors / therapeutic use
  • Humans
  • Pyridones / adverse effects
  • Retrospective Studies
  • Rivaroxaban / adverse effects


  • Rivaroxaban
  • Factor Xa Inhibitors
  • Anticoagulants
  • Dabigatran
  • Pyridones
  • Dexamethasone