Retrobulbar hematoma associated with selective serotonin reuptake inhibitor: A case report

Platelet function defects and sertraline-induced bleeding: a case report

A 71-year-old man is admitted for nose bleeds recurring for several days. His medical background shows in particular major depression for which he has been receiving sertraline for several years. The workup shows anemia, and no anomalies on head and neck CT angiography. However, further explorations suggest an acquired thrombopathy that could have contributed to the bleeding. During sertraline exposure, platelet functional exploration and platelet secretion were abnormal. Sertraline is often used as first-line treatment of depression. Pharmacological data and spontaneous notifications suggest increased potential risk with sertraline. It appears necessary to pay attention to bleeding with sertraline use.

Selective Serotonin Reuptake Inhibitors and Operative Bleeding Risk: A Review of the Literature

OBJECTIVE

This study aimed to review the data on the effect of selective serotonin reuptake inhibitors (SSRIs) on bleeding during or after operative procedures and to offer guidelines for clinical management.

DATA SOURCES

Search of PubMed and MEDLINE for all articles in English from 1990-2016 with key words depression, antidepressants, bleeding, platelets, and operation.

STUDY SELECTION

Studies were included if they reported information on bleeding complications during operative or childbirth procedures in patients taking antidepressants.

DATA EXTRACTION

Because of the limited number and heterogeneity of studies with respect to the range of operative procedures and definition of bleeding complications, a qualitative approach was taken to summarize results rather than abstracting and aggregating data.

RESULTS

The weight of the evidence is that SSRI use increases the risk of bleeding complications during and immediately after surgery. However, given the limited data, we cannot estimate the risk for a given patient having a given procedure.

CONCLUSIONS

Clinicians must consider the risk-to-benefit ratio of discontinuing an SSRI before an elective operative procedure. Discontinuing SSRI medications may result in discontinuation syndrome, symptom recrudescence, or relapse of depression, whereas continuing an SSRI during surgery exposes patients to significant bleeding risks. Antidepressant prescribers must be cognizant of and take responsibility for discussing this potential problem and considering different options. This issue must also be the responsibility of the doctor performing the procedure, but, frequently, it will be the prescribing physician who alerts the surgeon to the potential bleeding risk associated with SSRIs.

Serotonin Reuptake Inhibitors and Risk of Abnormal Bleeding

Serotonin reuptake inhibitors (SRIs) increase the risk of abnormal bleeding by lowering platelet serotonin and hence the efficiency of platelet-driven hemostasis; by increasing gastric acidity and possibly gastric ulceration; and by other mechanisms. The upper gastrointestinal tract is the commonest site of SRI-related abnormal bleeding; bleeding at this location may be increased by concurrent nonsteroidal anti-inflammatory drug therapy and by treatment with antiplatelet or anticoagulant drugs. Bleeding at this location may be reduced by concurrent administration of acid-suppressing drugs.

Assessing the Risks Associated with Antidepressant Use in Plastic Surgery: A Systematic Review

BACKGROUND

Antidepressant use has increased dramatically over the past decade. Although there is no question about the benefits of these medications, uncertainty exists with regard to the implications of antidepressant treatment surrounding plastic surgery. This systematic review collates all of the available literature that evaluates the risks of patient antidepressant treatment, in relation to plastic surgery.

METHODS

A comprehensive literature review of the PubMed and Cochrane databases was conducted. Articles were assessed by two independent reviewers using predefined data fields and selected using specific inclusion criteria. The two authors independently reviewed the literature and extracted data from included reviews, and discrepancies were resolved by consensus.

RESULTS

Twenty-six articles were included in the analysis and were categorized into five groups for comparison: risk of bleeding, risk of breast cancer, risk of breast cancer recurrence, breast enlargement, and miscellaneous (unique complications). Extracted information included study type, statistical analyses, conclusion, and limitations.

CONCLUSIONS

This review does not support the cessation of antidepressants in patients before plastic surgery, as the numbers needed to harm are low and the implications of withdrawal may prove to be detrimental to postoperative management. However, the use of antidepressants for mental disorders may also implicate key patient risk factors for surgical complications, and sufficient exploration into the patient's indications for the prescription is crucial. Evidence so far does not suggest that antidepressants increase the risk of breast cancer or recurrence in general, but caution should be exercised for those specifically on concurrent tamoxifen and paroxetine treatment.