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Patients with atrial fibrillation (AF) are at risk for developing rapid ventricular response and cardioembolic stroke. Although therapies to prevent these two serious complications are seemingly unrelated, drug–drug interactions may interfere with effective treatment. Diltiazem is a commonly used rate-control agent. It is also a potent inhibitor of CYP3A4 and a weak inhibitor of P-glycoprotein. Such inhibition leads to excess drug levels of medications metabolized via those pathways, including apixaban and rivaroxaban — anticoagulants commonly used for stroke prevention in AF. Data from small observational studies indicate that coadministration of these drugs may lead to increased bleeding.
In a study of 204,105 Medicare beneficiaries with A…