Ecchymoses as an adverse effect of fluoxetine treatment

Fluoxetine and Risk of Bleeding in Patients Aged 60 Years and Older Using the Korea Adverse Event Reporting System Database: A Case/Noncase Study

BACKGROUND

Depression, the leading cause of nonfatal disease burden, has a strong correlation with suicide and affects approximately 7% of the general elderly population. Adverse drug reactions in older patients are particularly important because of reduced drug metabolism, polypharmacy, drug-drug interactions, and drug-disease interactions. Fluoxetine is the first representative selective serotonin reuptake inhibitor but is associated with the possibility of hemorrhage based on its mechanism of action. Serious cases of gastrointestinal bleeding and cerebral hemorrhage have been reported, raising concerns about the safety of this drug.

METHODS

We detected signals of bleeding risk associated with fluoxetine in an elderly population using the Korea Adverse Event Reporting System database. Reporting odds ratios and 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 16,517 adverse events related to antidepressants were reported. The reporting odds ratios for fluoxetine were 2.34 (95% CI, 1.03-5.34) for total bleeding, 4.41 (95% CI, 1.60-12.15) for major bleeding, 2.06 (95% CI, 0.28-15.03) for gastrointestinal bleeding, and 6.12 (95% CI, 2.14-22.60) for brain hemorrhage compared with those of all other antidepressants.

CONCLUSIONS

We detected safety signals with total bleeding, major bleeding, and brain hemorrhage related to fluoxetine. For patients with a high risk of bleeding, such as the elderly population, prescribing antidepressants other than fluoxetine can be considered. The results of this study provide preliminary evidence of a relationship between fluoxetine and hemorrhage but have wide 95% CIs. Further pharmacoepidemiological studies will be needed to confirm the risk of bleeding associated with fluoxetine.

Sertraline-induced periorbital purpura: a case report

OBJECTIVE

The incidence of mild to severe levels of spontaneous bleeding due to the usage of selective serotonin reuptake inhibitors (SSRIs) is relatively low. Although the exact mechanism is not known, it is thought that inhibition of the serotonin transporter together with a decrease in platelet serotonin could be responsible for the bleeding. Therefore, the use of SSRIs in conjunction with anti-aggregants may predispose to or exacerbate the risk of bleeding. In this case report, we describe a 44-year-old female patient with a diagnosis of anxiety disorder who spontaneously developed periorbital purpura during treatment with sertraline.

CONCLUSION

Abnormal bleeding after treatment with an SSRI should be kept in mind, and alternative non-SSRI drugs of choice in such cases would be more appropriate. More extensive and comprehensive studies focusing on hemostasis and bleeding disorders are needed for SSRIs such as sertraline.

Breast ecchymosis: Unusual complication of an antidepressant agent

INTRODUCTION

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that is safely used for treatment of psychosomatic disorders. Despite being associated with a low side effect profile, it has been reported to cause hematological side effects including vaginal bleeding, epistaxis, purpura, hematuria, intracranial bleeding, and rectal bleeding. Isolated breast ecchymosis is one of exceedingly rare SSRI-induced hematological abnormalities.

PRESENTATION OF CASE

In this case study, we report a case of left breast ecchymosis in a 75-year-old woman that developed in conjunction with use of the SSRI fluoxetine.

DISCUSSION

The use of SSRIs has surged over the past decades due to increased diagnosis and focus on clinical management of depression and anxiety disorders, especially in developed nations. The low side effect profiles of the eight currently marketed SSRI agents has further promoted their use in the general population. While the most commonly reported side effects are mild and relatively tolerable, a risk of SSRI-related abnormal bleeding exists and may represent a life-threatening side effect. The most frequent SSRI-related bleeding manifestation is ecchymosis, but cases of isolated breast ecchymosis are exceedingly rare and to date only one report of SSRI-induced breast ecchymosis is included in the publicly available literature.

CONCLUSION

Three factors may have played a role in lack of reports describing SSRI-induced breast ecchymosis in literature. First, SSRIs indeed very seldom cause breast ecchymosis; second, physicians are not aware of such a causal relationship; and third, physicians find this side effect not worth to publish.