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Inglis JM, Caughey G, Thynne T, Brotherton K, Liew D, Mangoni AA, Shakib S. Association of Drug-Disease Interactions with Mortality or Readmission in Hospitalised Middle-Aged and Older Adults: A Systematic Review and Meta-Analysis. Drugs Real World Outcomes 2024; 11:345-360. [PMID: 38852118 PMCID: PMC11365905 DOI: 10.1007/s40801-024-00432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Multimorbidity is common in hospitalised adults who are at increased risk of inappropriate prescribing including drug-disease interactions. These interactions occur when a medicine being used to treat one condition exacerbates a concurrent medical condition and may lead to adverse health outcomes. The aim of this review was to examine the association between drug-disease interactions and the risk of mortality and readmission in hospitalised middle-aged and older adults. METHODS A systematic review was conducted on drug-disease interactions in hospitalised middle-aged (45-64 years) and older adults (≥65 years). The study protocol was prospectively registered with PROSPERO (Registration Number: CRD42022341998). Drug-disease interactions were defined as a medicine being used to treat one condition with the potential to exacerbate a concurrent medical condition or that were inappropriate based on a comorbid medical condition. Both observational and interventional studies were included. The outcomes of interest were mortality and readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, Web of Science, SCOPUS and the Cochrane Library from inception to 12 July, 2022. A meta-analysis was performed to pool risk estimates using the random-effects model. RESULTS A total of 563 studies were identified and four met the inclusion criteria. All were observational studies in older adults, with no studies identified in middle-aged adults. Most of the studies were at risk of bias because of an inadequate adjustment for covariates and a lack of clarity around individuals lost to follow-up. There were various definitions of drug-disease interactions within these four studies. Two studies assessed drugs that were contraindicated based on renal function, one assessed an individual drug-disease combination, and one was based on the clinical judgement of a pharmacist. There were two studies that showed an association between drug-disease interactions and the outcomes of interest. One reported that the use of diltiazem in patients with heart failure was associated with an increased risk of readmissions. The second reported that the use of medicines contraindicated according to renal function were associated with increased risk of all-cause mortality and a composite of mortality and readmission. Three of the studies (total study population = 5705) were amenable to a meta-analysis, which showed no significant association between drug-disease interactions and readmissions (odds ratio = 1.0, 95% confidence interval 0.80-1.38). CONCLUSIONS Few studies were identified examining the risk of drug-disease interactions and mortality and readmission in hospitalised adults. Most of the identified studies were at risk of bias. There is no universal accepted definition of drug-disease interactions in the literature. Further studies are needed to develop a standardised and accepted definition of these interactions to guide further research in this area.
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Affiliation(s)
- Joshua M Inglis
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia.
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia.
| | - Gillian Caughey
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Tilenka Thynne
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Kate Brotherton
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Danny Liew
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
- Department of General Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Sepehr Shakib
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
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2
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Haghbin H, Zakirkhodjaev N, Husain FF, Lee-Smith W, Aziz M. Risk of Gastrointestinal Bleeding with Concurrent Use of NSAID and SSRI: A Systematic Review and Network Meta-Analysis. Dig Dis Sci 2023; 68:1975-1982. [PMID: 36526813 DOI: 10.1007/s10620-022-07788-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 12/05/2022] [Indexed: 04/27/2023]
Abstract
INTRODUCTION Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used over-the-counter medications that can increase the risk of gastrointestinal (GI) bleeding through antiplatelet effects and loss of GI protection. Selective serotonin reuptake inhibitors (SSRIs), commonly used for mental and behavioral health, are another group of medications that can cause platelet dysfunction. Previous literature has shown a possible increased risk of GI bleeding with concurrent use of SSRIs and NSAIDs. We performed a network meta-analysis comparing NSAIDs, SSRIs, and combined SSRI/NSAIDs to assess the risk of GI bleeding. METHODS The following databases were searched: MEDLINE, Embase, Web of Science Core Collection, SciELO, KCI, and Cochrane database. All comparative studies, i.e., case-control, cohort, and randomized controlled trials were included. Direct and network meta-analysis was conducted using DerSimonian-Laird approach and random effect. For binary outcomes, odds ratio (OR) with 95% confidence interval (CI) and p value were calculated. RESULTS After a comprehensive search through November 10th, 2021, 15 studies with 82,605 patients were identified. 11 studies reported higher rates of GI bleeds in SSRI/NSAID than SSRI users (36.9% vs 22.8%, OR 2.14, 95% CI 1.52-3.02, p < 0.001, I2 = 86.1%). 10 studies compared SSRI/NSAID to NSAID users with higher rates of bleeds in SSRI/NSAID group (40.9% vs 34.2%, OR 1.49, 95% CI 1.20-1.84, p < 0.001, I2 = 68.8%). The results were consistent using network meta-analysis as well. CONCLUSION Given higher risk of bleeding with concurrent NSAIDs and SSRIs, prescribers should exercise caution when administering NSAIDs and SSRIs concurrently especially in patients with higher risks of GI bleeding.
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Affiliation(s)
- Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Hospital, Southfield, MI, USA.
| | | | | | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
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3
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Ahmed SH, El Ghareeb AEWA, El-Rahman HAA, Almaaty AHA. Impact of maternal desvenlafaxine exposure on brain development in pregnant albino rats and their fetuses. J Biochem Mol Toxicol 2022; 36:e23062. [PMID: 35363936 DOI: 10.1002/jbt.23062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/28/2021] [Accepted: 03/21/2022] [Indexed: 11/08/2022]
Abstract
Depression during pregnancy adversely affects fetal development. Desvenlafaxine drug is used for the treatment of gestational depression. In light of the well-established role of brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) in regulating neurogenesis and neural survival, the role of S100b in nerve cell energetic metabolism, differentiation of neurons and glial cells, an aberrant increase in NGF, BDNF and S100b expression in the fetal brain may contribute to desvenlafaxine cognitive disorders by altering brain development. This study is trying to determine the effect of desvenlafaxine on brain development. Thirty timed pregnant rats (from the 5th to the 20th day) were divided into three groups: control, low dose (5.14 mg/kg/day) and high dose (10.28 mg/kg/day) of desvenlafaxine where all animals received the corresponding doses by gavage. Maternal and fetal brain samples were fixed for histological, immunohistochemical (IHC) study of NGF and evaluated for BDNF and S100b genes expression. Desvenlafaxine induced some of the histopathological alterations in maternal and fetal rat brains. Moreover, IHC analysis of maternal and fetal rat brains showed that groups treated with desvenlafaxine demonstrated a significant increase of NGF protein immunoreactivity compared with that in the controls. Gene expression results revealed upregulation of messenger RNA BDNF and S100B expression. According to developmental changes in the brain, desvenlafaxine affects neonatal growth during pregnancy, which may lead to delay of brain development. So, it is essential to survey the roles of antidepressant drugs on neonatal development during pregnancy.
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Affiliation(s)
- Sarah H Ahmed
- Department of Zoology, Faculty of Science, Port Said University, Port Said, Egypt
| | | | | | - Ali H Abu Almaaty
- Department of Zoology, Faculty of Science, Port Said University, Port Said, Egypt
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4
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Tang J, Sharma U, Desai S, Molnar J, Perlmuter L, Feller A, Shah P. A Study of Proton Pump Inhibitors and Other Risk Factors in Warfarin-Associated Gastrointestinal Bleeding. Cureus 2021; 13:e12624. [PMID: 33585113 PMCID: PMC7872495 DOI: 10.7759/cureus.12624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Warfarin users are at increased risk for gastrointestinal bleeding (GIB). History of GIB, stroke, cardiovascular or chronic kidney disease, age greater than 65 years, and drug interaction with proton pump inhibitors (PPI) have previously been identified as risk factors for GIB in warfarin users. We hypothesized that concomitant use of warfarin and PPI would increase the incidence of GIB relative to warfarin use alone. Methods We did a retrospective review of medical records of 626 patients taking warfarin for at least two weeks. Parameters including age, concomitant medication use (non-steroidal anti-inflammatory drugs (NSAID), aspirin, selective serotonin reuptake inhibitors (SSRIs), PPI, and anti-platelet drug), history of GIB, chronic renal failure (CRF), and peptic ulcer disease (PUD) prior to warfarin use were analyzed. Results Variables that increase the likelihood of bleeding in warfarin users included aspirin, PPI, history of PUD, history of previous GIB, CRF, and elevated prothrombin time (PT)/international normalized ratio (INR) values. Concomitant antiplatelet use showed a slight increase in GIB but this was not statistically significant (p=0.082). NSAID use and SSRI use were not associated with a higher risk of GIB among warfarin users. Patients who are on PPI and warfarin simultaneously are more likely to be on acetylsalicylic acid (ASA) or have a history of PUD, GIB, or CRF, all of which are associated with increased incidences of GIB. Conclusions Although concomitant use of warfarin and PPI appears to be associated with an increased incidence of GIB, these patients are more likely to have other risk factors that also increase the risk of a GIB outcome. Therefore, the interaction between PPI and warfarin is clinically insignificant.
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Affiliation(s)
- Jevon Tang
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA
| | - Umesh Sharma
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA
| | - Shreya Desai
- Internal Medicine, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Janos Molnar
- Cardiology, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Lawrence Perlmuter
- Internal Medicine, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Axel Feller
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA
| | - Pallavi Shah
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA.,Internal Medicine, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
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5
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Korkmaz SA, Guney T, Dilek I, Caykoylu A. Interactions between Antidepressants and Warfarin: A Review. CURRENT PSYCHIATRY RESEARCH AND REVIEWS 2021. [DOI: 10.2174/2666082216999200622135657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Since warfarin has a very narrow therapeutic index, the interaction between
warfarin and antidepressants is very critical and has potentially severe consequences. It is unclear
whether clinicians have sufficient knowledge about the risk of bleeding when warfarin and antidepressants
are used concomitantly.
Objective:
In this systematic review, we discuss the main considerations when using warfarin with
antidepressants.
Methods:
The information about warfarin-antidepressant interactions was obtained from Google
Scholar®, PubMed/MEDLINE® and a hand search of the published literature. The following research
terms which were systematically combined with each other to find articles: warfarin, anticoagulant,
interactions, antidepressant (and each antidepressant name individually), SSRI, SNRI, TCA, MAOI.
Results:
Several possible mechanisms that can cause bleeding when antidepressants and warfarin
are used concomitantly, have been discussed. According to the available data, sertraline and citalopram/
escitalopram are safer antidepressants to use with warfarin, whereas fluoxetine and fluvoxamine
have a higher interaction potential with warfarin. The remaining antidepressants appear to lie
somewhere in between and have little empirical data to guide the clinicians.
Conclusion:
It is recommended that when an antidepressant is prescribed to a patient using warfarin,
patient’s international normalized ratio (INR) level should be checked regularly. In this review,
the interaction between warfarin and antidepressants, including new ones, were evaluated
inclusively and in detail.
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Affiliation(s)
| | - Tekin Guney
- Department of Hematology, University of Health Sciences Affiliated with of Ankara City Hospital, Ankara, Turkey
| | - Imdat Dilek
- Department of Hematology, Faculty of Medicine, Yildirim Beyazit University Affiliated with of Ankara City Hospital, Ankara, Turkey
| | - Ali Caykoylu
- Department of Psychiatry, Faculty of Medicine, Yildirim Beyazit University, Ankara, Turkey
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GİŞİ K, İSPİROĞLU M, KANTARÇEKEN B. NSAID Kullanan Her Hastada Gastrik Profilaksi Gerekli mi? KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2020. [DOI: 10.17517/ksutfd.671049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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7
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Martín Arias LH, Martín González A, Sanz Fadrique R, Salgueiro Vázquez E. Gastrointestinal safety of coxibs: systematic review and meta-analysis of observational studies on selective inhibitors of cyclo-oxygenase 2. Fundam Clin Pharmacol 2018; 33:134-147. [PMID: 30383903 DOI: 10.1111/fcp.12430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/24/2018] [Accepted: 10/30/2018] [Indexed: 12/27/2022]
Abstract
Prior meta-analyses have shown a higher gastrointestinal risk of nonselective NSAIDs versus placebo and a lower gastrointestinal risk of coxibs versus nonselective NSAIDs. However, the available data about gastrointestinal risk for coxibs versus placebo are scarce. The aim of this study was to review the current evidence on the use of coxibs and to evaluate the risk of gastrointestinal adverse outcomes (GAO) associated with coxibs versus nonexposed. Search was conducted on PubMed and Embase databases. We selected cohort observational, case-control, nested case-control and case-crossover studies that reported the risk of GAO associated with coxibs versus nonexposed as relative risk (RR), odds ratio (OR), hazard ratio (HR) or incidence rate ratio (IRR). It was estimated the pooled RR and the 95% confidence interval (CI) for coxibs both individually and as a whole by the DerSimonian and Laird method. Twenty-eight studies met inclusion criteria. Overall, coxibs were associated with a significant increment in the risk of GAO [RR 1.64 (95% CI 1.44-1.86)]. The analysis by individual drugs showed that etoricoxib [RR 4.85 (95% CI 2.64-8.93)] presented the highest gastrointestinal risk, followed by rofecoxib [RR 2.02 (95% CI 1.56-2.61)] and celecoxib [RR 1.53 (95% CI 1.19-1.97)]. Gastrointestinal risk was also high for the subgroups aged <65 years and low-dose coxibs. The use of coxibs is associated with a statistically significant increased risk of GAO, which would be high even for low-dose coxibs and <65-year-old subgroups. The risk would be higher for etoricoxib than for celecoxib and rofecoxib.
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Affiliation(s)
- Luis Hermenegildo Martín Arias
- Centre for Drug Surveillance (CESME), School of Medicine, Valladolid University, Av/Ramon y Cajal N°. 7, 47005, Valladolid, Spain
| | - Antonio Martín González
- Department of Pharmacy, Sagrado Corazón Hospital, C/Fidel Recio N.° 1, 47002, Valladolid, Spain
| | - Rosario Sanz Fadrique
- Centre for Drug Surveillance (CESME), School of Medicine, Valladolid University, Av/Ramon y Cajal N°. 7, 47005, Valladolid, Spain
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8
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Tomlin AM, Reith DM, Woods DJ, Lloyd HS, Smith A, Fountain JS, Tilyard MW. A Pharmacoepidemiology Database System for Monitoring Risk Due to the Use of Medicines by New Zealand Primary Care Patients. Drug Saf 2018; 40:1259-1277. [PMID: 28766108 DOI: 10.1007/s40264-017-0579-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The use of large record-linked healthcare databases for drug safety research and surveillance is now accepted practice. New Zealand's standardized national healthcare datasets provide the potential to automate the conduct of pharmacoepidemiological studies to provide rapid validation of medicine safety signals. OBJECTIVES Our objectives were to describe the methodology undertaken by a semi-automated computer system developed to rapidly assess risk due to drug exposure in New Zealand's population of primary care patients and to compare results from three studies with previously published findings. METHODS Data from three national databases were linked at the patient level in the automated studies. A retrospective nested case-control design was used to evaluate risk for upper gastrointestinal bleeding (UGIB), acute kidney failure (AKF), and serious arrhythmia associated with individual medicines, therapeutic classes of medicines, and concurrent use of medicines from multiple therapeutic classes. RESULTS The patient cohort available for each study included 5,194,256 patients registered between 2007 and 2014, with a total of 34,630,673 patient-years at risk. An increased risk for UGIB was associated with non-steroidal anti-inflammatory drugs (NSAIDs) (adjusted odds ratio [AOR] 4.16, 95% confidence interval [CI] 3.90-4.43, p < 0.001) and selective serotonin reuptake inhibitors (AOR 1.39, 95% CI 1.20-1.62, p < 0.001); an increased risk for AKF was associated with NSAIDs (AOR 1.78, 95% CI 1.73-1.83, p < 0.001) and proton pump inhibitors (AOR 1.78, 95% CI 1.72-1.83, p < 0.001); and an increased risk for serious arrhythmia was associated with fluoroquinolones (AOR 1.38, 95% CI 1.26-151, p < 0.001) and penicillins (AOR 1.69, 95% CI 1.61-1.77, p < 0.001). CONCLUSIONS Automated case-control studies using New Zealand's healthcare datasets can replicate associations of risk with drug exposure consistent with previous findings. Their speed of conduct enables systematic monitoring of risk for adverse events associated with a wide range of medicines.
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Affiliation(s)
| | - David M Reith
- Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, 9054, New Zealand
| | - David J Woods
- Best Practice Advocacy Centre, Dunedin, 9016, New Zealand.,Dunedin School of Pharmacy, University of Otago, Dunedin, 9054, New Zealand
| | - Hywel S Lloyd
- Best Practice Advocacy Centre, Dunedin, 9016, New Zealand.,Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, 9054, New Zealand
| | - Alesha Smith
- Best Practice Advocacy Centre, Dunedin, 9016, New Zealand.,Dunedin School of Pharmacy, University of Otago, Dunedin, 9054, New Zealand
| | | | - Murray W Tilyard
- Best Practice Advocacy Centre, Dunedin, 9016, New Zealand.,Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, 9054, New Zealand
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Wang SM, Han C, Bahk WM, Lee SJ, Patkar AA, Masand PS, Pae CU. Addressing the Side Effects of Contemporary Antidepressant Drugs: A Comprehensive Review. Chonnam Med J 2018; 54:101-112. [PMID: 29854675 PMCID: PMC5972123 DOI: 10.4068/cmj.2018.54.2.101] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 01/19/2023] Open
Abstract
Randomized trials have shown that selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have better safety profiles than classical tricyclic antidepressants (TCAs). However, an increasing number of studies, including meta-analyses, naturalistic studies, and longer-term studies suggested that SSRIs and SNRIs are no less safe than TCAs. We focused on comparing the common side effects of TCAs with those of newer generation antidepressants including SSRIs, SNRIs, mirtazapine, and bupropion. The main purpose was to investigate safety profile differences among drug classes rather than the individual antidepressants, so studies containing comparison data on drug groups were prioritized. In terms of safety after overdose, the common belief on newer generation antidepressants having fewer side effects than TCAs appears to be true. TCAs were also associated with higher drop-out rates, lower tolerability, and higher cardiac side-effects. However, evidence regarding side effects including dry mouth, gastrointestinal side effects, hepatotoxicity, seizure, and weight has been inconsistent, some studies demonstrated the superiority of SSRIs and SNRIs over TCAs, while others found the opposite. Some other side effects such as sexual dysfunction, bleeding, and hyponatremia were more prominent with either SSRIs or SNRIs.
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Affiliation(s)
- Sheng-Min Wang
- Department of Psychiatry, The Catholic University of Korea College of Medicine, Seoul, Korea.,International Health Care Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Changsu Han
- Department of Psychiatry, Korea University, College of Medicine, Seoul, Korea
| | - Won-Myoung Bahk
- Department of Psychiatry, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Soo-Jung Lee
- Department of Psychiatry, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ashwin A Patkar
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | | | - Chi-Un Pae
- Department of Psychiatry, The Catholic University of Korea College of Medicine, Seoul, Korea.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
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10
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Morley JE. The Effectiveness and Harms of Antidepressants. J Am Med Dir Assoc 2017; 18:279-281. [PMID: 28283382 DOI: 10.1016/j.jamda.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 01/18/2017] [Indexed: 01/16/2023]
Affiliation(s)
- John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, Missouri.
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11
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Laporte S, Chapelle C, Caillet P, Beyens MN, Bellet F, Delavenne X, Mismetti P, Bertoletti L. Bleeding risk under selective serotonin reuptake inhibitor (SSRI) antidepressants: A meta-analysis of observational studies. Pharmacol Res 2016; 118:19-32. [PMID: 27521835 DOI: 10.1016/j.phrs.2016.08.017] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 01/26/2023]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) have been reported to be potentially associated with an increased risk of bleeding. A meta-analysis of observational studies was conducted to quantify this risk. Case-control and cohort studies investigating bleeding risk under SSRI therapy were retrieved by searching the Medline, Pascal, Google Scholar and Scopus databases. Case-control studies were included if they reported bleeding incidents with and without the use of SSRIs and cohort studies were included if they reported the rate of bleeds among SSRI users and non-users. The main outcome was severe bleeding, whatever the site. Only data concerning SSRI belonging to the ATC class N06AB were used. For both case-control and cohort studies, we recorded the adjusted effect estimates and their 95% confidence intervals (CI). Pooled adjusted odds ratio (OR) estimates were computed for case-control and cohort studies using an inverse-variance model. Meta-analysis of the adjusted ORs of 42 observational studies showed a significant association between SSRI use and the risk of bleeding [OR 1.41 (95% CI 1.27-1.57), random effect model, p<0.0001]. The association was found for the 31 case-control studies (1,255,073 patients), with an increased risk of 41% of bleeding [OR 1.41 (95% CI 1.25-1.60)], as well as for the 11 cohort studies including 187,956 patients [OR 1.36 (95% CI 1.12-1.64)]. Subgroup analyses showed that the association remained constant whatever the characteristics of studies. This meta-analysis shows an increased risk of bleeding of at least 36% (from 12% to 64%) based on the high-level of observational studies with SSRIs use.
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Affiliation(s)
- Silvy Laporte
- INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, F-42023, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, Pharmacologie, CHU Saint-Etienne, Hôpital Nord, F-42055 France.
| | - Céline Chapelle
- INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, F-42023, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, Pharmacologie, CHU Saint-Etienne, Hôpital Nord, F-42055 France.
| | - Pascal Caillet
- Unité de Recherche Clinique, Innovation, Pharmacologie, CHU Saint-Etienne, Hôpital Nord, F-42055 France.
| | - Marie-Noëlle Beyens
- Centre Régional de Pharmacovigilance, CHU de Saint-Etienne, Hôpital Nord, F-42055, Saint-Etienne, France.
| | - Florelle Bellet
- Centre Régional de Pharmacovigilance, CHU de Saint-Etienne, Hôpital Nord, F-42055, Saint-Etienne, France.
| | - Xavier Delavenne
- INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, F-42023, Saint-Etienne, France; Laboratoire de Pharmacologie-Toxicologie, CHU de Saint-Etienne, Hôpital Nord, F-42055, Saint-Etienne, France.
| | - Patrick Mismetti
- INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, F-42023, Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Etienne, Hôpital Nord, F-42055, Saint-Etienne, France.
| | - Laurent Bertoletti
- INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, F-42023, Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Etienne, Hôpital Nord, F-42055, Saint-Etienne, France; INSERM, CIC1408, F-42055, Saint-Etienne, France.
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12
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Cheng YL, Hu HY, Lin XH, Luo JC, Peng YL, Hou MC, Lin HC, Lee FY. Use of SSRI, But Not SNRI, Increased Upper and Lower Gastrointestinal Bleeding: A Nationwide Population-Based Cohort Study in Taiwan. Medicine (Baltimore) 2015; 94:e2022. [PMID: 26579809 PMCID: PMC4652818 DOI: 10.1097/md.0000000000002022] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Selective serotonin receptor inhibitor (SSRI) and serotonin-noradrenaline reuptake inhibitor (SNRI) users have been reported to have an increased risk of upper gastrointestinal bleeding (UGIB), but their association with lower gastrointestinal bleeding (LGIB) is less studied. This study aimed to analyze the incidence of UGIB and LGIB among SSRI users, SNRI users, and controls.Using the National Health Insurance Research Database of Taiwan, 9753 subjects who were taking serotonin reuptake inhibitors (8809 with SSRIs, and 944 with SNRIs), and 39,012 age, sex, and enrollment time-matched controls were enrolled at a 1:4 ratio. The log-rank test was used to analyze differences in the cumulative hazard of UGIB and LGIB between groups. Cox proportional hazard regression analysis was used to evaluate the independent risk factors for UGIB and LGIB.During the 10-year follow-up period from 2000 to 2010, SSRI users, but not SNRI users, had significantly higher incidences of UGIB and LGIB than the controls (P < 0.001; log-rank test). The use of SSRIs, but not SNRIs, was independently associated with an increased risk of UGIB (hazard ratio [HR]:1.97; 95% confidence interval [CI]: 1.67-2.31) and LGIB (HR: 2.96, 95% CI: 2.46-3.57) after adjusting for age, sex, underlying comorbidities, and medications.The long-term use of SSRIs significantly increased the risk of UGIB and LGIB, and caused more LGIB than UGIB in the general population after adjusting for possible confounding factors, but the association between SNRIs and GIB is insignificant. Further prospective studies are needed to clarify this important issue.
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Affiliation(s)
- Yuan-Lung Cheng
- From the Department of Medicine (Y-LC, X-HL, J-CL, Y-LP, M-CH, H-CL, F-YL); Institute of Public Health and Department of Public Health, National Yang-Ming University, School of Medicine (H-YH); Division of Gastroenterology, Department of Medicine (Y-LC, X-HL, J-CL, Y-LP, H-CL, F-YL); Endoscopic Center for Diagnosis and Therapy (M-CH); Healthcare and Management Center, Taipei Veterans General Hospital, Taipei (M-CH); Department of Education and Research, Taipei City Hospital, Taipei City (H-YH); and Department of Medicine, Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan (Y-LC)
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Targownik LE. Are we worried enough about selective serotonin receptor inhibitors and upper gastrointestinal bleeding? Clin Gastroenterol Hepatol 2015; 13:51-4. [PMID: 25194804 DOI: 10.1016/j.cgh.2014.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 08/28/2014] [Accepted: 08/28/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Laura E Targownik
- Section of Gastroenterology, Department of Internal Medicine, IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
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Jiang HY, Chen HZ, Hu XJ, Yu ZH, Yang W, Deng M, Zhang YH, Ruan B. Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal bleeding: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2015; 13:42-50.e3. [PMID: 24993365 DOI: 10.1016/j.cgh.2014.06.021] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 06/15/2014] [Accepted: 06/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Selective serotonin reuptake inhibitors (SSRIs) are used to treat various psychiatric disorders. However, there are concerns that SSRIs increase the risk for upper gastrointestinal bleeding (UGIB). METHODS We performed a systematic review and meta-analysis of controlled observational studies to determine whether SSRI use affects the risk for UGIB. Our analysis included all observational studies that compared UGIB development among patients receiving SSRIs vs no treatment. We calculated pooled odds ratios using random- and fixed-effects models. RESULTS A total of 22 studies (6 cohort and 16 case-control studies) involving more than 1,073,000 individuals were included in our meta-analysis. In comparing SSRI users with patients who had not taken SSRIs, the odds for developing UGIB were 1.55-fold higher (odds ratio, 1.55; 95% confidence interval, 1.35-1.78). In subgroup analyses, the association was greatest for patients who received concurrent therapy with nonsteroidal anti-inflammatory or antiplatelet drugs; we found no significant increase in the risk of developing UGIB among patients receiving concurrent acid-suppressing drugs. CONCLUSIONS SSRI use was associated with an almost 2-fold increase in the risk of developing UGIB, especially among patients at high risk for GI bleeding (concurrent use of nonsteroidal anti-inflammatory or antiplatelet drugs). This risk might be reduced significantly by concomitant use of acid-suppressing drugs.
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Affiliation(s)
- Hai-Yin Jiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hua-Zhong Chen
- Department of Infectious Diseases, Taizhou Hospital Affiliated to Wenzhou Medical College, Linhai, Zhejiang, China
| | - Xin-Jun Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zheng-He Yu
- Department of Traditional Chinese Medicine, The Seventh People's Hospital of Hangzhou, Hangzhou, Zhejiang, China
| | - Wei Yang
- Department of Hematology, Integrated Chinese and Western Medicine Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Min Deng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yong-Hua Zhang
- Department of Traditional Chinese Medicine, The Seventh People's Hospital of Hangzhou, Hangzhou, Zhejiang, China.
| | - Bing Ruan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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Li H, Cheng Y, Ahl J, Skljarevski V. Observational study of upper gastrointestinal tract bleeding events in patients taking duloxetine and nonsteroidal anti-inflammatory drugs: a case-control analysis. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:167-74. [PMID: 25382984 PMCID: PMC4222172 DOI: 10.2147/dhps.s66835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose To determine whether the concomitant use of duloxetine with prescription nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin was associated with an increased risk for upper gastrointestinal (UGI) bleeding compared with taking these analgesics alone. Methods Truven Health Analytics MarketScan Research Databases were examined for hospital admissions of adult patients indexed from January 1, 2007–December 31, 2011. Cases were patients with UGI hemorrhage or peptic ulcer disease. Controls were randomly selected from the remaining admissions to match 10:1 with cases based on age, sex, and admission date. Prescription medication exposure groups of interest were: 1) no exposure to duloxetine, NSAIDs or aspirin; 2) duloxetine only; 3) NSAIDs or aspirin only; 4) duloxetine plus NSAIDs or aspirin. Logistic regression and relative excess risk due to interaction was utilized to estimate any increased risk of UGI bleeding for patients prescribed these medications across these groups. Results There were 33,571 cases and 335,710 controls identified. Comparing exposure group 2 and group 4, the adjusted odds ratio was 1.03 (95% confidence interval [CI], 0.94, 1.12), and the adjusted relative excess risk due to interaction was 0.352 (95% CI: –0.18, 0.72) for risk of UGI bleeding, neither of which support an increased risk or an interaction between duloxetine and prescription NSAID or aspirin for these events. Conclusion There was no evidence of an increased risk for UGI bleeding when duloxetine was taken with prescription NSAIDs or aspirin. In addition, there was no evidence of an interaction between duloxetine and prescription NSAIDs or aspirin for an increased risk of these events.
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Affiliation(s)
- Hu Li
- Neurosciences, Eli Lilly and Company, Indianapolis, IN, USA
| | - Yingkai Cheng
- Neurosciences, Eli Lilly and Company, Indianapolis, IN, USA
| | - Jonna Ahl
- Neurosciences, Eli Lilly and Company, Indianapolis, IN, USA
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Ryan PB, Schuemie MJ, Welebob E, Duke J, Valentine S, Hartzema AG. Defining a reference set to support methodological research in drug safety. Drug Saf 2014; 36 Suppl 1:S33-47. [PMID: 24166222 DOI: 10.1007/s40264-013-0097-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Methodological research to evaluate the performance of methods requires a benchmark to serve as a referent comparison. In drug safety, the performance of analyses of spontaneous adverse event reporting databases and observational healthcare data, such as administrative claims and electronic health records, has been limited by the lack of such standards. OBJECTIVES To establish a reference set of test cases that contain both positive and negative controls, which can serve the basis for methodological research in evaluating methods performance in identifying drug safety issues. RESEARCH DESIGN Systematic literature review and natural language processing of structured product labeling was performed to identify evidence to support the classification of drugs as either positive controls or negative controls for four outcomes: acute liver injury, acute kidney injury, acute myocardial infarction, and upper gastrointestinal bleeding. RESULTS Three-hundred and ninety-nine test cases comprised of 165 positive controls and 234 negative controls were identified across the four outcomes. The majority of positive controls for acute kidney injury and upper gastrointestinal bleeding were supported by randomized clinical trial evidence, while the majority of positive controls for acute liver injury and acute myocardial infarction were only supported based on published case reports. Literature estimates for the positive controls shows substantial variability that limits the ability to establish a reference set with known effect sizes. CONCLUSIONS A reference set of test cases can be established to facilitate methodological research in drug safety. Creating a sufficient sample of drug-outcome pairs with binary classification of having no effect (negative controls) or having an increased effect (positive controls) is possible and can enable estimation of predictive accuracy through discrimination. Since the magnitude of the positive effects cannot be reliably obtained and the quality of evidence may vary across outcomes, assumptions are required to use the test cases in real data for purposes of measuring bias, mean squared error, or coverage probability.
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Affiliation(s)
- Patrick B Ryan
- Janssen Research and Development LLC, 1125 Trenton-Harbourton Road, Room K30205, PO Box 200, Titusville, NJ, 08560, USA,
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Anglin R, Yuan Y, Moayyedi P, Tse F, Armstrong D, Leontiadis GI. Risk of upper gastrointestinal bleeding with selective serotonin reuptake inhibitors with or without concurrent nonsteroidal anti-inflammatory use: a systematic review and meta-analysis. Am J Gastroenterol 2014; 109:811-9. [PMID: 24777151 DOI: 10.1038/ajg.2014.82] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 03/11/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There is emerging concern that selective serotonin reuptake inhibitors (SSRIs) may be associated with an increased risk of upper gastrointestinal (GI) bleeding, and that this risk may be further increased by concurrent use of nonsteroidal anti-inflammatory (NSAID) medications. Previous reviews of a relatively small number of studies have reported a substantial risk of upper GI bleeding with SSRIs; however, more recent studies have produced variable results. The objective of this study was to obtain a more precise estimate of the risk of upper GI bleeding with SSRIs, with or without concurrent NSAID use. METHODS MEDLINE, EMBASE, PsycINFO, the Cochrane central register of controlled trials (through April 2013), and US and European conference proceedings were searched. Controlled trials, cohort, case-control, and cross-sectional studies that reported the incidence of upper GI bleeding in adults on SSRIs with or without concurrent NSAID use, compared with placebo or no treatment were included. Data were extracted independently by two authors. Dichotomous data were pooled to obtain odds ratio (OR) of the risk of upper GI bleeding with SSRIs +/- NSAID, with a 95% confidence interval (CI). The main outcome and measure of the study was the risk of upper GI bleeding with SSRIs compared with placebo or no treatment. RESULTS Fifteen case-control studies (including 393,268 participants) and four cohort studies were included in the analysis. There was an increased risk of upper GI bleeding with SSRI medications in the case-control studies (OR=1.66, 95% CI=1.44,1.92) and cohort studies (OR=1.68, 95% CI=1.13,2.50). The number needed to harm for upper GI bleeding with SSRI treatment in a low-risk population was 3,177, and in a high-risk population it was 881. The risk of upper GI bleeding was further increased with the use of both SSRI and NSAID medications (OR=4.25, 95% CI=2.82,6.42). CONCLUSIONS SSRI medications are associated with a modest increase in the risk of upper GI bleeding, which is lower than has previously been estimated. This risk is significantly elevated when SSRI medications are used in combination with NSAIDs, and physicians prescribing these medications together should exercise caution and discuss this risk with patients.
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Affiliation(s)
- Rebecca Anglin
- 1] Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada [2] Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Rueda-Lara M, Lopez-Patton MR. Psychiatric and psychosocial challenges in patients undergoing haematopoietic stem cell transplants. Int Rev Psychiatry 2014; 26:74-86. [PMID: 24716502 DOI: 10.3109/09540261.2013.866075] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Haematological malignancies are often treated with haematopoietic stem cell transplants (HSCT). The disease and its treatment are challenging and life threatening, as they not only affect the recipients, but also their families. This review highlights the available data on the psychological, psychiatric and social impact of these illnesses and their treatment on recipients and families. There are robust data that correlate HSCT with emotional distress, as emotional and physical functioning significantly affect quality of life. Psychiatric co-morbidity including anxiety, depression, adjustment and post-traumatic stress disorder, delirium and cognitive deficits have been reported at different stages in the transplant process. This review will highlight the psychosocial and clinical research findings relevant to HSCT patients and will summarize recommendations for future psychosocial research in this population.
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Affiliation(s)
- Maria Rueda-Lara
- University of Miami/Leonard Miller School of Medicine, Department of Psychiatry and Behavioral Sciences, Sylvester Comprehensive Cancer Center , Miami, Florida , USA
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Risk of perioperative blood transfusions and postoperative complications associated with serotonergic antidepressants in older adults undergoing hip fracture surgery. J Clin Psychopharmacol 2013; 33:790-8. [PMID: 24091859 DOI: 10.1097/jcp.0b013e3182a58dce] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Serotonergic antidepressants (SAds) are associated with bleeding-related adverse events. An increased risk of bleeding with SAds may have important implications in surgical settings. Our study evaluates the risk of red blood cell (RBC) transfusions and postoperative complications associated with SAds among older adults undergoing hip fracture surgery. We conducted a retrospective cohort study of individuals 66 years or older who underwent hip fracture surgery in Ontario, Canada. The risk of RBC transfusion among current users of SAds and nonserotonergic antidepressants (NSAds) was compared with recent former SAd users. Secondary outcomes included measures of postoperative morbidity and mortality. Subgroup analyses were undertaken in groups who were coprescribed other medications known to effect bleeding. Multivariable logistic regression was utilized to determine the odds ratios (ORs) for antidepressants and postoperative outcomes. A total 11,384 individuals were included in the study sample. Current SAd users had an increased risk of RBC transfusion compared with recent former users of SAds (OR, 1.28; 95% confidence interval, 1.14-1.43) as did current NSAd users (OR, 1.17; 95% confidence interval, 1.03-1.33). The risk of RBC transfusion with SAds or NSAds was further increased among individuals receiving antiplatelet agents. However, postoperative morbidity and mortality were not increased among either group of antidepressant users. In conclusion, SAds are associated with an increased risk of RBC transfusions, although this does not appear to result in major postoperative complications. Clinicians should be aware of this increased risk, although routine discontinuation of antidepressants before surgery is likely unwarranted in most cases.
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Tavakoli HR, DeMaio M, Wingert NC, Rieg TS, Cohn JA, Balmer RP, Dillard MA. Serotonin reuptake inhibitors and bleeding risks in major orthopedic procedures. PSYCHOSOMATICS 2013; 53:559-65. [PMID: 23157994 DOI: 10.1016/j.psym.2012.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 04/25/2012] [Accepted: 04/26/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Risk of abnormal bleeding in surgery patients prescribed serotonin reuptake inhibitors (SRIs) is unclear. Considering the quantity of literature on abnormal gastrointestinal (GI) bleeding with SRIs, relatively little exists on SRI bleeding risks in surgical procedures. We investigated whether SRIs increase the risk of surgical bleeding in patients undergoing knee and hip total joint replacement. METHODS RA retrospective case-control study was conducted among subjects undergoing primary total hip and knee replacement surgeries from January 2005 to March 2011 at a single institution. The experimental group was defined by utilization of SRIs at the time of surgery (the independent variable). The control group was matched for age, sex, ethnicity, and type of surgery (hip or knee). Any case with preoperative hematocrit <30, platelets <100,000; abnormal prothrombin time, partial-prothrombin time, and international normalized ratio (INR), primary bleeding disorder, medical conditions, or medications associated with increased bleeding was excluded. All cases were randomly selected. RESULTS RA total of 194 subjects (hip 104, knee 90) were included. Statistical analysis was performed on the SRI group (n = 71) and the control, non-SRI group (n = 123). No difference was found between the groups in estimated blood loss, hemoglobin, hematocrit, platelets, PT, PTT, and INR from preoperative to postoperative day 1, 2, and 3. Furthermore, no subjects in either group required blood transfusions. CONCLUSION SRIs were not associated with increased risk of bleeding in primary knee or hip replacement surgeries in this study. The hypothesis that SRIs increase the risk of bleeding based on presumptions about their action on platelet aggregation is uncertain and warrants further study.
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Affiliation(s)
- Hamid R Tavakoli
- Dept. of Psychiatry, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.
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Perahia DG, Bangs ME, Zhang Q, Cheng Y, Ahl J, Frakes EP, Adams MJ, Martinez JM. The risk of bleeding with duloxetine treatment in patients who use nonsteroidal anti-inflammatory drugs (NSAIDs): analysis of placebo-controlled trials and post-marketing adverse event reports. DRUG HEALTHCARE AND PATIENT SAFETY 2013; 5:211-9. [PMID: 24348072 PMCID: PMC3849082 DOI: 10.2147/dhps.s45445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose To assess the safety of duloxetine with regards to bleeding-related events in patients who concomitantly did, versus did not, use nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin. Methods Safety data from all placebo-controlled trials of duloxetine conducted between December 1993 and December 2010, and post-marketing reports from duloxetine-treated patients in the US Food and Drug Administration Adverse Event Reporting System (FAERS), were searched for bleeding-related treatment-emergent adverse events (TEAEs). The percentage of patients with bleeding-related TEAEs was summarized and compared between treatment groups in all the placebo-controlled studies. Differences between NSAID user and non-user subgroups from clinical trial data were analyzed by a logistic regression model that included therapy, NSAID use, and therapy-by-NSAID subgroup interaction. In addition, to determine if higher duloxetine doses are associated with an increased incidence of bleeding-related TEAEs, and whether the use of concomitant NSAIDs might influence the dose effect if one exists, placebo-controlled clinical trials with duloxetine fixed doses of 60 mg, 120 mg, and placebo were analyzed. Also, the incidence of bleeding-related TEAEs reported for duloxetine alone was compared with the incidence in patients treated with duloxetine and concomitant NSAIDs. Finally, the number of bleeding-related cases reported for duloxetine in the FAERS database was compared with the numbers reported for all other drugs. Results Across duloxetine clinical trials, there was a significantly greater incidence of bleeding-related TEAEs in duloxetine- versus placebo-treated patients overall and also in those patients who did not take concomitant NSAIDS, but no significant difference was seen among those patients who did take concomitant NSAIDS. There was no significant difference in the incidence of bleeding-related TEAEs in the subset of patients treated with duloxetine 120 mg once daily versus those treated with 60 mg once daily regardless of concomitant NSAID use. The combination of duloxetine and NSAIDs was associated with a statistically significantly higher incidence of bleeding-related TEAEs compared with duloxetine alone. A similarly higher incidence of bleeding-related TEAEs was seen in patients treated with placebo and concomitant NSAIDs compared with placebo alone. Bleeding-related TEAEs reported in the FAERS database were disproportionally more frequent for duloxetine taken with NSAIDs compared with the full FAERS background, but there was no difference in the reporting of bleeding-related TEAEs when the cases reported for duloxetine taken with NSAIDs were compared against the cases reported for NSAIDs alone. Conclusion Concomitant use of NSAIDs was associated with a higher incidence of bleeding-related TEAEs in clinical trials regardless of whether patients were taking duloxetine or placebo; bleeding-related TEAEs did not appear to increase along with duloxetine dose regardless of NSAID use. In spontaneously reported post-marketing data, the combination of duloxetine and NSAID use was not associated with an increased reporting of bleeding-related events when compared to NSAID use alone.
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Affiliation(s)
- David G Perahia
- Neurosciences, Lilly Research Centre, Windlesham, Surrey, UK
| | - Mark E Bangs
- Neurosciences, Eli Lilly and Company, Indianapolis, IN, USA
| | - Qi Zhang
- Neurosciences, Eli Lilly and Company, Indianapolis, IN, USA
| | - Yingkai Cheng
- Neurosciences, Eli Lilly and Company, Indianapolis, IN, USA
| | - Jonna Ahl
- Neurosciences, Eli Lilly and Company, Indianapolis, IN, USA
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Stang PE, Ryan PB, Overhage JM, Schuemie MJ, Hartzema AG, Welebob E. Variation in Choice of Study Design: Findings from the Epidemiology Design Decision Inventory and Evaluation (EDDIE) Survey. Drug Saf 2013; 36 Suppl 1:S15-25. [PMID: 24166220 DOI: 10.1007/s40264-013-0103-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paul E Stang
- Janssen Research and Development LLC, Titusville, NJ, USA,
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Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013; 48:439-47. [PMID: 23356751 PMCID: PMC3613943 DOI: 10.3109/00365521.2012.763174] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The authors aimed to investigate the incidence and outcomes of acute upper gastrointestinal bleeding (AUGIB) and to examine the role of drugs potentially associated with AUGIB. METHODS The study was prospective, population-based and consisted of all patients who underwent upper gastrointestinal endoscopy (UGE), during the year of 2010 at the National University Hospital of Iceland. Drug intake of NSAIDs, low-dose aspirin (LDA), warfarin, SSRIs and bisphosphonates prior to GIB was prospectively registered and also checked in a Pharmaceutical Database covering all prescriptions in Iceland. An age- and gender-matched control group consisted of patients who underwent UGE during the study period and were without GIB. RESULTS A total of 1731 patients underwent 2058 UGEs. Overall, 156 patients had AUGIB. The crude incidence for AUGIB was 87/100,000 inhabitants per year. The most common etiologies were duodenal (21%) and gastric ulcers (15%). Use of LDA (40% vs. 30%), NSAIDs (20% vs. 8%), warfarin (15% vs. 7%), combination of NSAIDs + LDA (8% vs. 1%) and SSRIs + LDA (8% vs. 3%) were significantly more common among bleeders than non-bleeders. Three patients (1.9%) had emergency surgery and two patients died of AUGIB. Independent predictors of clinically significant bleeding were gastric ulcer (OR 6.6, p = 0.012) and NSAIDs (OR 6.6, p = 0.004). CONCLUSIONS LDA, NSAIDs and warfarin play an important role in AUGIB etiology and particularly combinations of drugs. Gastric ulcer and NSAIDs were independent predictors of severe bleeding. Mortality and the need for surgery during hospitalization was low in this population-based setting.
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Affiliation(s)
- Jóhann P. Hreinsson
- Department of Internal Medicine, The National University Hospital of Iceland, Section of Gastroenterology and Hepatology, Reykjavík, Iceland
| | | | | | - Einar S. Björnsson
- Department of Internal Medicine, The National University Hospital of Iceland, Section of Gastroenterology and Hepatology, Reykjavík, Iceland
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Luo JC, Leu HB, Hou MC, Huang KW, Lin HC, Lee FY, Chan WL, Lin SJ, Chen JW. Nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients. Am J Med 2013; 126:264.e25-32. [PMID: 23410569 DOI: 10.1016/j.amjmed.2012.09.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 09/07/2012] [Accepted: 09/20/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Hemodialysis patients carry a higher risk of peptic ulcer bleeding. Whether hemodialysis patients also have a higher occurrence of nonpeptic ulcer, nonvariceal gastrointestinal bleeding needs further evaluation. METHODS Using Taiwan's National Health Insurance research database, the occurrence of nonpeptic ulcer, nonvariceal gastrointestinal bleeding was compared among the hemodialysis patients, chronic kidney disease patients, and controls using log-rank test. Risk factors were identified by Cox regression analysis. RESULTS A total of 20,830 patients were enrolled, including 8210 hemodialysis and 4190 chronic kidney disease patients and 8430 age- and sex-matched controls in a 2:1:2 ratio. In the 7-year follow-up period, hemodialysis patients had a significantly higher cumulative hazard of nonpeptic ulcer, nonvariceal gastrointestinal bleeding than chronic kidney disease patients and controls (P <.001, by log-rank test). The hazard also was significantly higher in the chronic kidney disease patients than in controls. Cox regression analysis revealed that older age, the comorbidities of diabetes mellitus, cirrhosis, and chronic obstructive pulmonary disease, history of uncomplicated peptic ulcer disease, chronic kidney disease (hazard ratio 5.17), hemodialysis (hazard ratio 9.43), and use of selective serotonin reuptake inhibitors were independent risk factors for nonpeptic ulcer, nonvariceal gastrointestinal bleeding in all study patients. Old age, diabetes mellitus, cirrhosis, chronic obstructive pulmonary disease, history of uncomplicated peptic ulcer disease, and use of selective serotonin reuptake inhibitors were independent risk factors in hemodialysis patients. CONCLUSIONS There is a higher risk of developing nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients after adjustments for age, sex, underlying comorbidities, and ulcerogenic medication. The risk has increased since patients had chronic kidney disease.
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Affiliation(s)
- Jiing-Chyuan Luo
- Department of Medicine, National Yang-Ming University, School of Medicine, Taipei City, Taiwan.
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Lower gastrointestinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol 2013; 25:37-43. [PMID: 23013623 DOI: 10.1097/meg.0b013e32835948e3] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To investigate the incidence and outcomes of acute lower gastrointestinal bleeding (ALGIB) in a population-based setting and examine the role of drugs potentially associated with GIB. METHODS The study was prospective and population based. The cohort included all patients who underwent colonoscopy during the year 2010 at the National University Hospital of Iceland. Indications for endoscopies and drug history were recorded in a systematic manner. The inclusion criteria were overt bleeding leading to hospitalization or occurring in hospitalized patients. The use of NSAIDs, low-dose aspirin, warfarin, selective serotonin receptor inhibitors, and bisphosphonates before GIB was also checked in a Pharmaceutical Database covering all drug prescriptions in the country. A control group included patients who underwent colonoscopy during the study period and did not have GIB. RESULTS Altogether, 1134 patients underwent 1275 colonoscopies. Overall, 163 patients had ALGIB. The crude incidence for ALGIB was 87/100 000 inhabitants/year. The most common findings were diverticulosis (23%) and ischemic colitis (16%). A total of 7.4% of individuals had endoscopic therapy and none had undergone surgery. Two (1.2%) patients died because of ALGIB, both with severe comorbidities. Overall, 19% with ALGIB were on NSAIDs versus 9% in nonbleeders (P=0.0096); 37% with ALGIB were on low-dose aspirin versus 25% in nonbleeders (P=0.0222). CONCLUSION The incidence for ALGIB is the highest reported to date. The most common reasons for ALGIB were diverticulosis and ischemic colitis. Mortality during hospitalization was very low. NSAIDs and low-dose aspirin seem to increase the risk for ALGIB.
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Antidepressant use and the risk of upper gastrointestinal bleeding in psychiatric patients: a nationwide cohort study in Taiwan. J Clin Psychopharmacol 2012; 32:518-24. [PMID: 22722503 DOI: 10.1097/jcp.0b013e31825ccd5a] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The magnitude of risk between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding (UGIB) is still unknown in patients with psychiatric diseases. The aim of this study was to quantify the risk of UGIB induced by use of antidepressants with different affinities for serotonin transporters in psychiatric patients using Taiwan's nationwide health insurance claims database. We conducted a propensity score- matched retrospective cohort study and identified 304,606 psychiatric patients who initiated antidepressant treatment during the 2005-2006 period. Antidepressants were classified as high- (HA group), intermediate- (IA group), or low-affinity (LA group) serotonin reuptake inhibitors. Patients in the LA group were matched 1:1 to those in the HA and IA groups according to their propensity scores. Subjects who were successfully matched were followed up from the date of antidepressant initiation to first hospitalization for UGIB, drug discontinuation, transition to or addition of antidepressants in another group, or the study's end (whichever occurred first). A total of 153,486 psychiatric patients were successfully matched, and 498 first UGIB events were identified. Compared with the LA group, patients in the HA group had a higher risk for UGIB (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.11-1.71). The HR (95% CI) of the IA group was 1.11 (95% CI, 0.88-1.41). The trend for elevated UGIB risk with increasing affinity of serotonin transporters was statistically significant (P < 0.01). Elderly patients and those with prior UGIB history were more susceptible to the harmful effects. Our findings suggest that the use of high-affinity serotonin reuptake inhibitors may increase the risk for UGIB in psychiatric patients.
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Wahl PM, Gagne JJ, Wasser TE, Eisenberg DF, Rodgers JK, Daniel GW, Wilson M, Schneeweiss S, Rassen JA, Patrick AR, Avorn J, Bohn RL. Early steps in the development of a claims-based targeted healthcare safety monitoring system and application to three empirical examples. Drug Saf 2012; 35:407-16. [PMID: 22489640 DOI: 10.2165/11594770-000000000-00000] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Several efforts are under way to develop and test methods for prospective drug safety monitoring using large, electronic claims databases. Prospective monitoring systems must incorporate signalling algorithms and techniques to mitigate confounding in order to minimize false positive and false negative signals due to chance and bias. OBJECTIVE The aim of the study was to describe a prototypical targeted active safety monitoring system and apply the framework to three empirical examples. METHODS We performed sequential, targeted safety monitoring in three known drug/adverse event (AE) pairs: (i) paroxetine/upper gastrointestinal (UGI) bleed; (ii) lisinopril/angioedema; (iii) ciprofloxacin/Achilles tendon rupture (ATR). Data on new users of the drugs of interest were extracted from the HealthCore Integrated Research Database. New users were matched by propensity score to new users of comparator drugs in each example. Analyses were conducted sequentially to emulate prospective monitoring. Two signalling rules--a maximum sequential probability ratio test and an effect estimate-based approach--were applied to sequential, matched cohorts to identify signals within the system. RESULTS Signals were identified for all three examples: paroxetine/UGI bleed in the seventh monitoring cycle, within 2 calendar years of sequential data; lisinopril/angioedema in the second cycle, within the first monitoring year; ciprofloxacin/ATR in the tenth cycle, within the fifth year. CONCLUSION In this proof of concept, our targeted, active monitoring system provides an alternative to systems currently in the literature. Our system employs a sequential, propensity score-matched framework and signalling rules for prospective drug safety monitoring and identified signals for all three adverse drug reactions evaluated.
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Affiliation(s)
- Peter M Wahl
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Womens Hospital, Harvard Medical School, Boston, MA 02120, USA.
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Blasco-Fontecilla H, de Leon J. Lower Gastrointestinal Bleeding and Paroxetine Use: Two Case Reports. PSYCHOSOMATICS 2012; 53:184-7. [DOI: 10.1016/j.psym.2011.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 08/27/2011] [Accepted: 08/30/2011] [Indexed: 10/28/2022]
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Teichert M, Visser LE, Uitterlinden AG, Hofman A, Buhre PJ, Straus S, De Smet PAGM, Stricker BH. Selective serotonin re-uptake inhibiting antidepressants and the risk of overanticoagulation during acenocoumarol maintenance treatment. Br J Clin Pharmacol 2012; 72:798-805. [PMID: 21545482 DOI: 10.1111/j.1365-2125.2011.04004.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIM The aim of this study was to investigate the effects of co-medication with selective serotonin re-uptake inhibitors (SSRIs) on overanticoagulation during acenocoumarol maintenance treatment. METHODS All subjects from The Rotterdam Study who received acenocoumarol maintenance treatment between April 1 1991 and September 9 2009 were followed for the event of an international normalized ratio (INR) ≥6, until death, end of treatment or end of the study period. With the Andersen-Gill extension of the Cox proportional hazards model, risks for repeated events of overanticoagulation in relation to concomitant SSRI use were calculated. RESULTS The risk for overanticoagulation during acenocoumarol maintenance treatment was increased in combination with fluvoxamine (HR 2.63, 95% CI 1.49, 4.66) and venlafaxine (HR 2.19, 95% CI 1.21, 3.99). There was no increase in risk for the other SSRIs, but numbers of exposed cases were low for all SSRIs except paroxetine. CONCLUSION Fluvoxamine and venlafaxine were associated with a more than double risk of INR values ≥6 in acenocoumarol treated subjects.
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Affiliation(s)
- Martina Teichert
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.
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Reikvam AG, Hustad S, Reikvam H, Apelseth TO, Nepstad I, Hervig TA. The effects of selective serotonin reuptake inhibitors on platelet function in whole blood and platelet concentrates. Platelets 2012; 23:299-308. [DOI: 10.3109/09537104.2011.618852] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
INTRODUCTION Bleeding is the major complication associated with warfarin therapy. Some antidepressants are also associated with increased bleeding risk. Warfarin and antidepressants are used frequently in combination, but it is unclear whether concomitant use increases the risk of bleeding beyond that with warfarin alone. The primary goal of this study was to determine whether the use of warfarin and an antidepressant increases the risk for bleeding outcomes compared with the use of warfarin alone. The secondary goal was to characterize the risk of bleeding in warfarin-treated patients taking one specific class of antidepressant, selective serotonin reuptake inhibitors (SSRIs). MATERIALS AND METHODS This was a retrospective, single-center, study of warfarin-treated patients prescribed (n = 46) and not prescribed (n = 54) an antidepressant. Medical records over 6 months were reviewed for international normalized ratio values, medical history, bleeding type and incidence, and hospitalization due to bleeding. Patients were included in the antidepressant group if they were taking concomitant warfarin and antidepressant therapy consistently for a period of 6 months and in the control group if they were not taking an antidepressant with warfarin. RESULTS The use of any antidepressant with warfarin was not associated with the incidence of any bleeding or major bleeding during the 6-month period. However, the use of an SSRI with warfarin was associated with an increase in any bleeding event (odds ratio 2.6, 95% confidence interval, 1.01-6.4 P = 0.04). The use of an SSRI remained a significant predictor of bleeding after accounting for other factors associated with bleeding risk. CONCLUSIONS Based on these data, it is important to clarify the interaction between warfarin and SSRIs in regard to bleeding risk given the high frequency of their concomitant use.
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Siddiqui R, Gawande S, Shende T, Tadke R, Bhave S, Kirpekar V. SSRI-induced coagulopathy: is it reality? Ther Adv Psychopharmacol 2011; 1:169-74. [PMID: 23983943 PMCID: PMC3736913 DOI: 10.1177/2045125311423781] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To study the effect of escitalopram and fluoxetine on coagulation profile in patients with major depression. METHOD This was a prospective, open-label, single-centre study in 40 patients diagnosed with major depressive disorder. The patients were diagnosed using Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria. Twenty patients receiving escitalopram 10 mg per day and 20 patients receiving fluoxetine 20 mg per day participated in the study and were followed up for 3 months. Coagulation parameters - bleeding time, clotting time, platelet count, prothrombin time and partial thromboplastin kaolin time - were evaluated at baseline and after 3 months. RESULTS At the end of 3 months, a significant increase in bleeding time was seen in patients receiving fluoxetine, but within the normal range. No rise was seen in the group given escitalopram. CONCLUSION In patients with depression, fluoxetine increases bleeding time whereas escitalopram has no effect on coagulation profile. However, both the drugs can be used safely for long-term treatment.
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de Abajo FJ. Effects of selective serotonin reuptake inhibitors on platelet function: mechanisms, clinical outcomes and implications for use in elderly patients. Drugs Aging 2011; 28:345-67. [PMID: 21542658 DOI: 10.2165/11589340-000000000-00000] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Among the antidepressants, the selective serotonin reuptake inhibitors (SSRIs) are often preferred to other classes of antidepressants in the treatment of depression in the elderly because of their better safety profile. Most of the known effects of SSRIs, either beneficial or adverse, are linked to their inhibitory action on the serotonin reuptake transporter (5-HTT). This reuptake mechanism is present not only in neurons but also in other cells such as platelets. Serotoninergic mechanisms seem to play an important role in haemostasis, and their importance in this regard has long been underestimated. Abnormal activation may lead to a pro-thrombotic state, as may occur in patients with major depressive disorder, whilst downregulation, as occurs in patients treated with SSRIs, may have two clinical consequences, both of particular interest in the elderly. On the one hand, there may be an increased risk of bleeding; on the other hand, a reduction in thrombotic risk may be possible. Polymorphism in the promoter region of the gene that transcribes the 5-HTT has been shown to have a relevant impact on its function and, in turn, on the beneficial and adverse effects of SSRIs. Bleeding has been a concern since the introduction of SSRIs, with multiple case reports published and communicated to the pharmacovigilance systems. The first epidemiological study was published in 1999 and since then, 34 epidemiological studies from different areas, most of them including elderly patients in their study populations, have been published with a variety of results. Broadly, the epidemiological evidence supports a moderately increased risk of bleeding associated with the use of SSRIs, which may be critically dependent on patient susceptibility and the presence of risk factors. The impairment of primary haemostasis induced by SSRIs may result, as a beneficial counterpart, in a reduction in the thrombotic risk. A small number of clinical trials and an increasing number of epidemiological studies that include elderly patients have been conducted to clarify whether SSRIs reduce the risk of primary and secondary ischaemic disorders. However, the results have been inconclusive with some studies suggesting a preventive effect and others no effect or even an increased risk. Behind such contradictory results may be the role of depression itself as a cardiovascular risk factor and, therefore, a major confounding factor. How to disentangle its effect from that of the antidepressants is the methodological challenge to be overcome in future studies. In this complex scenario, the elderly seem to be at a crossroads, because they are the group in which both the risks and the benefits can be the greatest. Studies performed to date have provided us with some clues that can help orient clinicians in taking the most appropriate course of action. For instance, as the gastrointestinal bleeding risk appears to increase with age, prudent advice in patients with a previous history of upper-gastrointestinal bleeding or peptic ulcer, and in those who take NSAIDs, oral anticoagulants, antiplatelet drugs or corticosteroids, would be to suggest addition of an acid-suppressing agent to the drug regimen in those elderly patients in whom SSRIs are indicated.
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Affiliation(s)
- Francisco J de Abajo
- Clinical Pharmacology Unit, Hospital Universitario Príncipe de Asturias, Madrid, Spain
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Napeñas JJ, Hong CHL, Kempter E, Brennan MT, Furney SL, Lockhart PB. Selective serotonin reuptake inhibitors and oral bleeding complications after invasive dental treatment. ACTA ACUST UNITED AC 2011; 112:463-7. [PMID: 21821439 DOI: 10.1016/j.tripleo.2011.04.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 04/13/2011] [Accepted: 04/21/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the frequency of oral bleeding complications after invasive dental procedures in patients taking selective serotonin reuptake inhibitor (SSRI) medications. STUDY DESIGN In this retrospective cohort study, we included dental patients who had invasive dental treatment and were taking an SSRI medication. Data collected included demographics, medical history, dental visits and procedures, and use of adjunctive measures to control bleeding. Primary outcomes included documentation of return visits or phone calls to the dental clinic or emergency department (ED) for oral bleeding, and oral bleeding or use of blood products for inpatients. RESULTS There were 92 patients taking SSRIs who had 145 invasive procedure visits, consisting of extractions, implant surgery, alveoloplasty, periodontal surgery, subgingival scaling and root planning, and biopsy. There were 110 extraction visits yielding a total of 167 extractions. Among all patients, there was 1 return visit to the clinic and 1 telephone call with a chief complaint of oral bleeding. CONCLUSIONS The frequency of oral bleeding complications after invasive dental treatment is low to negligible in patients on SSRI medications.
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Affiliation(s)
- Joel J Napeñas
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC 28232, USA.
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Kumar D, Saaraswat T, Sengupta SN, Mehrotra S. Upper gastrointestinal bleeding in a patient with depression receiving selective serotonin reuptake inhibitor therapy. Indian J Pharmacol 2011; 41:51-3. [PMID: 20177584 PMCID: PMC2825017 DOI: 10.4103/0253-7613.48881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 08/20/2008] [Accepted: 02/04/2009] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Serotonin plays an important role in the normal clotting phenomenon and is released by platelets. Platelets are dependent on a serotonin transporter for the uptake of serotonin, as they cannot synthesize it themselves. Selective serotonin reuptake inhibitors (SSRIs) block the uptake of serotonin into platelets and can cause problems with clotting leading to bleeding. AIM This case report highlights the occurrence of upper gastrointestinal bleeding in the index case on initiating SSRI therapy for depression and the prompt resolution of the same on its discontinuation on two separate occasions. CONCLUSION SSRIs may cause upper gastrointestinal (GI) bleeding. Physicians should be aware of the same and should try to rule out previous episodes of upper GI bleed or the presence of other risk factors which might predispose to it before prescribing SSRIs; they should also warn the patients about this potential side effect. Also, the presence of thalassemia trait in the index patient deserves special attention and needs to be explored to see if it might in any way contribute in potentiating this side effect of SSRIs.
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Affiliation(s)
- Deepak Kumar
- Department of Psychiatry, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi, India
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Richter JA, Patrie JT, Richter RP, Henry ZH, Pop GH, Regan KA, Peura DA, Sawyer RG, Northup PG, Wang AY. Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel. Gastrointest Endosc 2011; 74:22-34.e1. [PMID: 21704806 DOI: 10.1016/j.gie.2011.03.1258] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 03/29/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding. OBJECTIVE To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement. DESIGN Retrospective cohort study. SETTING Large quaternary-care academic medical center. PATIENTS A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009. INTERVENTIONS PEG tube placement. MAIN OUTCOME MEASUREMENTS GI bleeding. RESULTS Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any dose) or clopidogrel and post-PEG bleeding. However, SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04). LIMITATIONS Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients. CONCLUSIONS Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding.
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Carvajal A, Ortega S, Del Olmo L, Vidal X, Aguirre C, Ruiz B, Conforti A, Leone R, López-Vázquez P, Figueiras A, Ibáñez L. Selective serotonin reuptake inhibitors and gastrointestinal bleeding: a case-control study. PLoS One 2011; 6:e19819. [PMID: 21625637 PMCID: PMC3097219 DOI: 10.1371/journal.pone.0019819] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 04/17/2011] [Indexed: 11/18/2022] Open
Abstract
Background Selective serotonin reuptake inhibitors (SSRIs) have been associated with upper gastrointestinal (GI) bleeding. Given their worldwide use, even small risks account for a large number of cases. This study has been conducted with carefully collected information to further investigate the relationship between SSRIs and upper GI bleeding. Methods We conducted a case-control study in hospitals in Spain and in Italy. Cases were patients aged ≥18 years with a primary diagnosis of acute upper GI bleeding diagnosed by endoscopy; three controls were matched by sex, age, date of admission (within 3 months) and hospital among patients who were admitted for elective surgery for non-painful disorders. Exposures to SSRIs, other antidepressants and other drugs were defined as any use of these drugs in the 7 days before the day on which upper gastrointestinal bleeding started (index day). Results 581 cases of upper GI bleeding and 1358 controls were considered eligible for the study; no differences in age or sex distribution were observed between cases and controls after matching. Overall, 4.0% of the cases and 3.3% of controls used an SSRI antidepressant in the week before the index day. No significant risk of upper GI bleeding was encountered for SSRI antidepressants (adjusted odds ratio, 1.06, 95% CI, 0.57–1.96) or for whichever other grouping of antidepressants. Conclusions The results of this case-control study showed no significant increase in upper GI bleeding with SSRIs and provide good evidence that the magnitude of any increase in risk is not greater than 2.
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Affiliation(s)
- Alfonso Carvajal
- Instituto de Farmacoepidemiología, Universidad de Valladolid, Valladolid, Spain.
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Itatsu T, Nagahara A, Hojo M, Miyazaki A, Murai T, Nakajima M, Watanabe S. Use of selective serotonin reuptake inhibitors and upper gastrointestinal disease. Intern Med 2011; 50:713-7. [PMID: 21467703 DOI: 10.2169/internalmedicine.50.4644] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) are the most widely used antidepressants in the world. Recent studies, however, have raised the concern that SSRIs increase the risk of gastrointestinal dysfunction. Therefore, we conducted a case-control study on gastrointestinal symptoms and endoscopic findings in patients who were taking SSRIs in Japan. METHODS Forty-one patients who were taking SSRIs (SSRI-treated group) and 82 age- and sex-matched patients who were not taking antidepressants (control group) were selected from the population of patients who underwent endoscopic examination from January 1, 2005 to March 31, 2010 in our institution, and their subjective symptoms and endoscopic findings were analyzed. Patients who were taking proton pump inhibitors (PPIs) and/or histamine H(2)-receptor antagonists (H2RAs) were excluded from this study. RESULTS The chief complaints at the endoscopic examination were classified into the following 4 categories: reflux symptoms, dysmotility symptoms, ulcer-like symptoms, and no upper abdominal symptoms. No significant difference was found in the complaint rate of each category between the SSRI-treated and the control groups. No significant differences were found between the groups in endoscopic findings, the LANZA score and the rate of chief complaints in patient classes stratified by the endoscopic finding. CONCLUSION It was not evident that SSRIs induced mucosal damage of the upper gastrointestinal tract. And, it is considered that SSRIs do not increase the risk of upper gastrointestinal symptoms in patients treated with SSRIs for 1 month or longer. The present study suggests that SSRI medication does not have a bad influence on gastrointestinal symptoms and gastrointestinal organic diseases.
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Affiliation(s)
- Tomoko Itatsu
- Department of Internal Medicine, Juntendo Koshigaya Hospital, Japan
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Biosensors for brain trauma and dual laser doppler flowmetry: enoxaparin simultaneously reduces stroke-induced dopamine and blood flow while enhancing serotonin and blood flow in motor neurons of brain, in vivo. SENSORS 2010; 11:138-61. [PMID: 22346571 PMCID: PMC3274119 DOI: 10.3390/s11010013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 11/18/2010] [Accepted: 12/06/2010] [Indexed: 12/16/2022]
Abstract
Neuromolecular Imaging (NMI) based on adsorptive electrochemistry, combined with Dual Laser Doppler Flowmetry (LDF) is presented herein to investigate the brain neurochemistry affected by enoxaparin (Lovenox(®)), an antiplatelet/antithrombotic medication for stroke victims. NMI with miniature biosensors enables neurotransmitter and neuropeptide (NT) imaging; each NT is imaged with a response time in milliseconds. A semiderivative electronic reduction circuit images several NT's selectively and separately within a response time of minutes. Spatial resolution of NMI biosensors is in the range of nanomicrons and electrochemically-induced current ranges are in pico- and nano-amperes. Simultaneously with NMI, the LDF technology presented herein operates on line by illuminating the living brain, in this example, in dorso-striatal neuroanatomic substrates via a laser sensor with low power laser light containing optical fiber light guides. NMI biotechnology with BRODERICK PROBE(®) biosensors has a distinct advantage over conventional electrochemical methodologies both in novelty of biosensor formulations and on-line imaging capabilities in the biosensor field. NMI with unique biocompatible biosensors precisely images NT in the body, blood and brain of animals and humans using characteristic experimentally derived half-wave potentials driven by oxidative electron transfer. Enoxaparin is a first line clinical treatment prescribed to halt the progression of acute ischemic stroke (AIS). In the present studies, BRODERICK PROBE(®) laurate biosensors and LDF laser sensors are placed in dorsal striatum (DStr) dopaminergic motor neurons in basal ganglia of brain in living animals; basal ganglia influence movement disorders such as those correlated with AIS. The purpose of these studies is to understand what is happening in brain neurochemistry and cerebral blood perfusion after causal AIS by middle cerebral artery occlusion in vivo as well as to understand consequent enoxaparin and reperfusion effects actually while enoxaparin is inhibiting blood clots to alleviate AIS symptomatology. This research is directly correlated with the medical and clinical needs of stroke victims. The data are clinically relevant, not only to movement dysfunction but also to the depressive mood that stroke patients often endure. These are the first studies to image brain neurotransmitters while any stroke medications, such as anti-platelet/anti-thrombotic and/or anti-glycoprotein are working in organ systems to alleviate the debilitating consequences of brain trauma and stroke/brain attacks.
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Ahsberg K, Höglund P, Kim WH, von Holstein CS. Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding. Scand J Gastroenterol 2010; 45:1404-15. [PMID: 20695720 DOI: 10.3109/00365521.2010.510567] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the impact of increased use of low-dose aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), warfarin, corticosteroids and selective serotonin re-uptake inhibitors (SSRIs) on the site and outcome of non-variceal gastrointestinal (GI) bleeds. METHODS Retrospective review of 731 patients with peptic ulcer bleeds (PUBs), non-ulcer, non-variceal upper (NUUPGIBs) and lower GI bleeds (LGIBs) in 1984, 1994 and 2004 at Lund University Hospital, Sweden. Incidence and mortality rates, risk factors for fatal outcome and associations with different sites of GI bleeds were evaluated. RESULTS Between 1984 and 2004, incidence of PUBs decreased from 62.0 to 32.1 per 100,000 inhabitants (p<0.001). Incidence of NUUPGIBs (29.0-30.4 per 100,000) and LGIBs (45.5-43.2 per 100,000) was stable. The case-fatality rate ranged from 4-6% (p=0.65) for upper GI bleed to 1-8% (p=0.033) for LGIB. No drug impacted on fatal outcome. Aspirin, warfarin and SSRI users tended to suffer more severe GI bleeds than non-users of these drugs. When comparing non-ulcer GI bleeds with PUBs, aspirin (OR 0.56, 95% CI 0.38-0.82) was more strongly associated with PUBs, whereas SSRIs (OR 3.71, 95% CI 1.39-12.9) and corticosteroids (OR 2.8, 95% CI 1.28-6.82) were more associated with non-ulcer GI bleeds after adjusting for age, gender and co-morbidity. CONCLUSION Increased use of drugs that promote bleeding has not impacted on incidence and fatal outcome of non-variceal GI bleeds, although the severity of bleeding has increased. Aspirin is more strongly associated with PUBs, while corticosteroids and SSRIs are associated with non-ulcer, non-variceal GI bleeds.
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Affiliation(s)
- Kristina Ahsberg
- Department of Surgery, Lund University Hospital, Lund University, Lund, Sweden.
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Dall M, Schaffalitzky de Muckadell OB, Lassen AT, Hallas J. There is an association between selective serotonin reuptake inhibitor use and uncomplicated peptic ulcers: a population-based case-control study. Aliment Pharmacol Ther 2010; 32:1383-91. [PMID: 21050241 DOI: 10.1111/j.1365-2036.2010.04472.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Persons who use serotonin reuptake inhibitors (SSRIs) seem to be at increased risk of having serious upper gastrointestinal bleeding. In vitro studies have shown that SSRIs inhibit platelet aggregation. It remains unknown if SSRIs have a direct ulcerogenic effect. AIM To investigate if there is a possible association between use of SSRIs and uncomplicated peptic ulcers. METHODS A population-based case-control study was conducted in the county of Funen, Denmark, using local prescription database and patient register. The 4862 cases all had a first diagnosis of uncomplicated peptic ulcers from 1995 to 2009. Controls (n = 19 448), matched for age and gender, were selected by risk-set sampling. RESULTS The adjusted odds ratios (OR) of uncomplicated peptic ulcers among current, recent and past users of SSRIs were 1.50 (95% CI 1.18-1.90), 1.56 (95% CI 0.98-2.49) and 1.32 (95% CI 1.08-1.61). There was no association with tricyclic antidepressants [OR 0.94 (95% CI 0.65-1.35)]. The adjusted OR for the SSRI-uncomplicated peptic ulcers association was 0.76 (95% CI 0.46-1.25) among users of proton pump inhibitors. CONCLUSIONS Use of SSRI is associated with uncomplicated peptic ulcers, possibly by some effect on the healing process. We cannot exclude some effects of residual confounding or bias by frequent physician contact.
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Affiliation(s)
- M Dall
- University of Southern Denmark, Odense C, Denmark.
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Kringen MK, Narum S, Lygren I, Seljeflot I, Sandset PM, Trøseid AMS, Johansen PW, Brørs O, Holthe MR. Reduced platelet function and role of drugs in acute gastrointestinal bleeding. Basic Clin Pharmacol Toxicol 2010; 108:194-201. [PMID: 21118353 DOI: 10.1111/j.1742-7843.2010.00643.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Gastrointestinal (GI) bleeding may be caused by a constitutive bleeding disposition or drug-induced inhibition of hemostasis. Platelet function in patients with ongoing GI bleeding is unknown. The aim of this study was to investigate platelet function in patients with acute GI bleeding. Patients (n=35) presenting with acute GI bleeding (hematemesis or melena) were recruited. For comparison, 13 patients treated with aspirin and 11 patients treated with clopidogrel without GI bleeding and 27 healthy controls were studied. Platelet function was measured by whole-blood aggregation and flow cytometry. Coagulation function was measured with calibrated automated thrombography. Platelet aggregation and P-selectin expression were significantly lower after arachidonic acid stimulation in GI bleeding patients than in healthy subjects (p≤0.05). Collagen-induced P-selectin expression was significantly reduced in patients using anti-platelet drugs (p=0.02) and in many patients not using anti-platelet drugs. Thrombin generation, measured by calibrated automated thrombography, was only reduced in patients on warfarin treatment. In conclusion, platelet function is reduced in acute GI bleeding patients and a considerable proportion appears to be related to drug use.
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Affiliation(s)
- Marianne K Kringen
- Department of Pharmacology, Oslo University Hospital, Ullevål, Kirkeveien 166, Oslo, Norway.
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Piatkov I, Rochester C, Jones T, Boyages S. Warfarin toxicity and individual variability-clinical case. Toxins (Basel) 2010; 2:2584-92. [PMID: 22069565 PMCID: PMC3153177 DOI: 10.3390/toxins2112584] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Revised: 10/21/2010] [Accepted: 10/27/2010] [Indexed: 11/16/2022] Open
Abstract
Warfarin is a widely used anticoagulant in the treatment and prevention of thrombosis, in the treatment for chronic atrial fibrillation, mechanical valves, pulmonary embolism, and dilated cardiomyopathy. It is tasteless and colorless, was used as a poison, and is still marketed as a pesticide against rats and mice. Several long-acting warfarin derivatives-superwarfarin anticoagulants-such as brodifacoum, diphenadione, chlorophacinone, bromadiolone, are used as pesticides and can produce profound and prolonged anticoagulation. Several factors increase the risk of warfarin toxicity. However, polymorphisms in cytochrome P450 genes and drug interactions account for most of the risk for toxicity complications. Each person is unique in their degree of susceptibility to toxic agents. The toxicity interpretation and the health risk of most toxic substances are a subject of uncertainty. Genetically determined low metabolic capacity in an individual can dramatically alter the toxin and metabolite levels from those normally expected, which is crucial for drugs with a narrow therapeutic index, like warfarin. Personalized approaches in interpretation have the potential to remove some of the scientific uncertainties in toxicity cases.
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Affiliation(s)
- Irina Piatkov
- Diversity Health Institute, DHI Laboratory, ICPMR level 2, Sydney-West Area Health Service, Westmead Hospital, Westmead, NSW 2145, Australia.
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Strubel T, Birkhofer A, Mössmer G, Förstl H. [SSRI - treatment and bleeding. What risks do we take?]. DER NERVENARZT 2010; 81:549-55. [PMID: 19693477 DOI: 10.1007/s00115-009-2824-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Treatment with selective serotonin reuptake inhibitors (SSRI) increases the risk of gastrointestinal bleeding. The combination with non-steroidal anti-inflammatory drugs (NSAIDs) further augments this hazard. Particular precaution is also necessary in patients on platelet aggregation inhibitors, with a known bleeding disorder or preceding gastrointestinal lesions. The incidence of bleeding events apart from the gastrointestinal tract, e.g. intracerebral hemorrhages, is not cumulated under SSRI treatment. This also applies for the combination of SSRI and coumarin or aspirin. Prescribing doctors have to be aware of the bleeding risks of SSRI and should explain this to their patients. High-risk patients have to be followed up closely and an SSRI with a low potential for drug interaction should be used. The prescription of gastroprotective agents and a change of the antidepressant should be considered in particular cases. We provide a literature survey and recommendations for the clinical routine.
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Affiliation(s)
- T Strubel
- Klinikum rechts der Isar, Klinik und Poliklinik für Psychiatrie und Psychotherapie der TU München, Ismaningerstrasse 22, 81675, München, Deutschland.
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Abstract
Anticoagulants and psychotropic medications are commonly prescribed together. Thus, the potential for interaction exists. Whereas thrombolytics and heparins are implicated in few pharmacokinetic interactions, warfarin and platelet inhibitors have been implicated in various interactions with psychotropic medications. In this article, I review the various psychotropic drug classes' relationships to anticoagulants. In a field devoid of randomized, placebo-controlled trials, clinical vigilance is advised when managing patients on concomitant therapy.
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46
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An association between selective serotonin reuptake inhibitor use and serious upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2009; 7:1314-21. [PMID: 19716436 DOI: 10.1016/j.cgh.2009.08.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 08/11/2009] [Accepted: 08/15/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In vitro studies have shown that selective serotonin reuptake inhibitors (SSRIs) inhibit platelet aggregation. It is controversial whether use of SSRIs is a cause of clinically important bleeding; results from observational studies have been equivocal. METHODS A population-based case-control study was conducted in Denmark. The 3652 cases all had a first discharge diagnosis of serious upper gastrointestinal bleeding (UGB) from 1995 to 2006. Controls (n = 36,502), matched for age and sex, were selected by risk-set sampling. Data on drug exposure and medical history were retrieved from a prescription database and the county's patient register. Confounders were controlled for by conditional logistic regression and the case-crossover design. RESULTS The adjusted odds ratio (OR) of UGB among current, recent, and past users of SSRIs was 1.67 (95% confidence interval [CI], 1.46-1.92), 1.88 (95% CI, 1.42-2.5), and 1.22 (95% CI, 1.07-1.39). The adjusted OR for concurrent use of SSRI and nonsteroidal anti-inflammatory drugs (NSAIDs) was 8.0 (95% CI, 4.8-13). The adjusted OR for the concurrent use of NSAID, aspirin, and SSRI was 28 (95% CI, 7.6-103). Of the UGB cases, 377 were current users of SSRI; the adjusted OR for UGB in the case crossover analysis was 2.8 (95% CI, 2.2-3.6). The adjusted OR among users of proton pump inhibitors was 0.96 (95% CI, 0.50-1.82). CONCLUSIONS Use of SSRI was associated with UGB, consistent with its antiplatelet effects. SSRIs should be prescribed with caution for patients at high risk for UGB.
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Moret C, Isaac M, Briley M. Problems associated with long-term treatment with selective serotonin reuptake inhibitors. J Psychopharmacol 2009; 23:967-74. [PMID: 18635702 DOI: 10.1177/0269881108093582] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Although the selective serotonin reuptake inhibitors (SSRIs), which are now widely used as a first-line treatment for depression and many other psychiatric conditions, are generally well tolerated, they are not devoid of side effects. Most short-term treatment-related side effects of SSRIs are transient and disappear after a few days or weeks. However, following long-term treatment with the SSRIs, some serious adverse events may occur. Some of them can be difficult to recognise because they can resemble residual symptoms of depression. The most serious can be life threatening. They all have a negative influence on the patient's quality of life and are frequently a prime reason for a lack of long-term compliance with the associated increased risk of recurrence of a depressive episode. This article is an overview of the more common adverse events, which are seen with non-acute treatment with the SSRIs.
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Affiliation(s)
- C Moret
- NeuroBiz Consulting & Communication, Castres, France.
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48
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Retrobulbar hematoma associated with selective serotonin reuptake inhibitor: A case report. ACTA ACUST UNITED AC 2009; 108:e1-2. [DOI: 10.1016/j.tripleo.2009.06.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Revised: 05/15/2009] [Accepted: 06/29/2009] [Indexed: 11/23/2022]
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49
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McCarthy DM. GI bleeding: problems that persist. Gastrointest Endosc 2009; 70:225-8. [PMID: 19631801 DOI: 10.1016/j.gie.2008.12.247] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 12/28/2008] [Indexed: 02/08/2023]
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Hedayati SS, Finkelstein FO. Epidemiology, diagnosis, and management of depression in patients with CKD. Am J Kidney Dis 2009; 54:741-52. [PMID: 19592143 DOI: 10.1053/j.ajkd.2009.05.003] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 05/06/2009] [Indexed: 11/11/2022]
Affiliation(s)
- S Susan Hedayati
- Division of Nephrology, Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas, TX, USA
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