109 - Overall

Overall

Depression and anxiety disorders CHAPTER 3 A review of 13 studies found an increased odds ratio (a range of 1.21 to 4.14) of perioperative bleeding with SSRIs.59 One study noted an increased risk of bleeding in women undergoing breast surgery60 and the authors suggest withholding SSRIs for 2  weeks prior to such planned surgery. Venlafaxine may have similar effects59 but duloxetine may not affect bleeding risk.61 Alternatives to SSRIs/SNRIs Non-­SSRI antidepressants such as mirtazapine and bupropion have been suggested as safer alternatives to SSRIs and SNRIs.62 Preliminary studies suggest mirtazapine, bupropion and nortriptyline have minimal effects on measurable clotting mechanisms.63 However, there is little evidence that these drugs are safer and one meta-­analysis found an increased risk of UGIB with mirtazapine (vs no treatment) and no difference in bleeding risk between mirtazapine or bupropion and SSRIs.64 Overall Serotonergic antidepressants increase the risk of various types of bleeding, especially when prescribed alongside oral anticoagulants of any kind.36,65,66 Evidence is strongest for SSRIs and it is likely that risk of bleeding is related to affinity for the serotonin transporter. SSRIs increase the risk of GI bleeding, haemorrhagic stroke, perioperative bleeding, postpartum haemorrhage and uterine bleeding. Their effect is exacerbated by co-­prescription with aspirin, anticoagulants and NSAIDs. In most cases, the use of SSRIs increases the risk of an event by a clinically meaningful extent, but especially when co-­prescribed with other drugs that affect clotting. Summary ■ ■SSRIs increase the risk of GI, uterine, cerebral and perioperative bleeding. ■ ■Risk is increased still further in those also receiving aspirin, NSAIDs or oral anticoagulants. ■ ■Try to avoid SSRIs/SNRIs in patients receiving NSAIDs, aspirin or oral anticoagulants or in those with a history of cerebral or GI bleeds. ■ ■Safer alternatives have not been definitively identified but noradrenergic antidepressants (nortriptyline, bupropion) are preferred. ■ ■If SSRI/SNRI use cannot be avoided, monitor closely and prescribe gastroprotective PPIs. ■ ■Limited evidence suggests that bleeding risks may be lower with less potent serotonin reuptake inhibitors (Table 3.19). References

1. Skop BP, et al. Potential vascular and bleeding complications of treatment with selective serotonin reuptake inhibitors. Psychosomatics 1996; 37:12–16.
2. Laporte S, et al. Bleeding risk under selective serotonin reuptake inhibitor (SSRI) antidepressants: a meta-­analysis of observational studies. Pharmacol Res 2017; 118:19–32.
3. Andrade C, et al. Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and a reconsideration of mechanisms. J Clin Psychiatry 2010; 71:1565–1575.
4. Dall M, et al. There is an association between selective serotonin reuptake inhibitor use and uncomplicated peptic ulcers: a population-­based case–control study. Aliment Pharmacol Ther 2010; 32:1383–1391.