A Possible Drug-Drug Interaction Between Eliquis and Amiodarone Resulting in Hemopericardium

According to the ARISTOTLE trial, apixaban was superior to warfarin because it was associated with fewer strokes, systemic embolism, and bleeding. Hemopericardium was one of the major bleeding events reported in this trial. However, the percentage of patients that developed hemopericardium was not stated in the trial results. We present a case of hemopericardium in an 80-year-old man admitted for dyspnea, cough, and lower extremity edema. He was recently diagnosed with paroxysmal atrial fibrillation and started on apixaban for stroke prevention. Prior to admission, he was taking metoprolol succinate and amiodarone for atrial fibrillation. His symptoms resolved after undergoing successful pericardiocentesis. Although hemopericardium is a rare side effect associated with the use of non-vitamin K oral anticoagulants (NOACs), we suspect that a drug-drug interaction between apixaban and amiodarone (via the cytochrome p450 system and p-glycoprotein efflux pumps), the patient's advanced age, and borderline creatinine are possible risk factors.