Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks

A Hematoma in the Anterior Abdominal Muscle in a Woman Receiving Venlafaxine: A Literature Review of the Reports on Similar Cases

INTRODUCTION

Venlafaxine (VEN) is a selective norepinephrine reuptake inhibitor (SNRI) that mainly helps treat major depressive disorder and anxiety and panic disorders. It works by inhibiting the reuptake of serotonin (5-hydroxytryptamine, 5-HT) and noradrenaline (NA) by presynaptic neurons. Additionally, VEN administration has been linked with a bleeding predisposition that may be due to the inhibition of NA and 5-HT uptake by platelets which have their own receptors on their surface and are implicated in platelet aggregation.

CASE PRESENTATION

Herein, we report a case of a 54-year-old patient treated with VEN, who presented with a hematoma in the anterior abdominal muscle. We also present the observational studies and case reports highlighting the association of SNRIs use with various hemorrhagic complications ranging from gastrointestinal hemorrhage or vaginal bleeding to bleeding during or after surgery due to either thrombocytopenia or impaired platelet aggregation.

CONCLUSION

Given the cases of either reductions in the platelet count or impairment of platelet activity accompanied by bleeding events, every clinician should be aware of these possible adverse effects when prescribing SNRIs.

Selective Serotonin Reuptake Inhibitors and Other Treatment Modalities for Deep Space Missions

INTRODUCTION: As humankind ventures further into the depths of space, planning is already underway for long-duration exploration missions that will test the bounds of human performance. Deep space travel will include added risk related to stressors from the isolated, confined, and extreme environment that lies outside the boundaries of low Earth orbit. Currently, selective serotonin reuptake inhibitors (SSRIs) are considered the standard of care for many mental health diagnoses, including anxiety and depression; however, SSRIs are also associated with several undesired side effects. The utility of nonpharmacological therapies for the management of behavioral health conditions has not yet been fully explored.METHODS: A comprehensive literature search was performed using PubMed. Relevant articles pertaining to the psychological impacts of isolated, confined, and extreme environments, use of SSRIs in spaceflight, side effects associated with SSRIs, and nonpharmacological treatments for anxiety and depression were reviewed. Over 70 studies were reviewed in total.RESULTS: Reduced bone mineral density, impaired hemostatic function, significant individual variability resulting from gene polymorphisms, and drug-drug interactions are well described adverse effects of SSRIs that may complicate their operational use in the deep space environment. Four alternative therapies for the treatment of anxiety and depression may show promise for long duration missions.DISCUSSION: Although SSRIs have long been considered standard of care treatment for many behavioral health conditions, we cannot trivialize the risk that prolonged pharmacological therapy may pose. The need to mitigate these risks by exploring alternative therapies has never been more relevant.El-Khoury BB, Ray KL, Altchuler SI, Reichard JF, Dukes CH. Selective serotonin reuptake inhibitors and other treatment modalities for deep space missions. Aerosp Med Hum Perform. 2023; 94(11):843-851.

Cardiovascular adverse reactions associated with escitalopram in patients with underlying cardiovascular diseases: a systematic review and meta-analysis

Background

Despite the anticipated efficacy of escitalopram in treating depression and anxiety in individuals with preexisting cardiovascular conditions, persistent concerns regarding its adverse effects have emerged. In this systematic review, we aimed to evaluate the cardiovascular safety profile of escitalopram compared with that of placebo in patients with underlying cardiovascular disease.

Methods

We used a predefined search strategy in PubMed, Cochrane Central Register of Controlled Trials, Embase, International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify studies evaluating adverse cardiovascular reactions to escitalopram in patients with underlying cardiovascular disease. Randomized controlled trials (RCTs) that provided results on cardiovascular safety outcomes were included. Two independent reviewers screened the abstracts and full texts of the individual studies. The risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

Results

The primary outcomes were the frequency of major adverse cardiovascular events (MACE), QTc prolongation, and discontinuation of study medication. We identified 5 RCTs with 773 participants who met the inclusion criteria. Escitalopram was not associated with significantly increased risk of MACE (risk ratio [RR] = 1.85; 95% confidence interval [CI] 0.80 to 4.26; I2 0%; 5 RCTs; n = 773, moderate certainty of evidence), discontinuation of study medication (RR = 1.03; 95% CI 0.84-1.26; I2 0%; 5 RCTs; n = 773, low certainty of evidence), and QTc prolongation (RR = 1.20; 95% CI 0.76-1.90; I2 0%; 4 RCTs; n = 646, low certainty of evidence).

Conclusion

Escitalopram does not significantly increase the risk of cardiovascular adverse reactions compared with placebo in patients with underlying cardiovascular disease. However, the presence of wide CIs and the limited number of included studies highlight the need for further studies with larger sample sizes to enhance the precision and reliability of these findings.Systematic review registration: International Prospective Register of Systematic Reviews [CRD42022298181].

The 2023 Impact of Inflammatory Bowel Disease in Canada: Mental Health and Inflammatory Bowel Disease

Psychiatric disorders are 1.5 to 2 times more prevalent in persons with inflammatory bowel disease (IBD) than in the general population, with pooled prevalence estimates of 21% for clinical anxiety and 15% for depression. Rates are even higher when considering mental health symptoms, as nearly one-third of persons with IBD experience elevated anxiety symptoms and one-quarter experience depression symptoms. Rates of these symptoms were much higher during periods of disease activity, more common in women than men, and more common in Crohn's disease than ulcerative colitis. There is robust evidence of the detrimental effects of comorbid depression and anxiety on the subsequent course of IBD based on longitudinal studies tracking outcomes over time. However, psychiatric disorders and IBD have bidirectional effects, with each affecting risk of the other. Elevated mental health concerns have been consistently associated with greater healthcare utilization and costs related to IBD. There is some signal that low resilience in adolescence could be a risk factor for developing IBD and that enhancing resilience may improve mental health and intestinal disease outcomes in IBD. Psychological therapies used to treat anxiety and depression occurring in the context of IBD have been shown to significantly improve the quality of life for persons with IBD and reduce anxiety and depression. There is less evidence in regard to the impact of psychotropic medications on mental health or disease outcomes in persons with IBD. There is consensus, however, that mental health must be addressed as part of comprehensive IBD care for children and adults.

Hematochezia caused by tandospirone in a patient with major depressive disorder and anxious distress: a case report

Background

Major depressive disorder (MDD) with anxious distress is a relatively common condition that is often associated with a poor treatment response. In order to enhance the effectiveness of MDD treatment, 5-HT1A agonists like tandospirone are often prescribed in conjunction with antidepressants. While it is known that antidepressants can increase the risk of bleeding, whether tandospirone poses a similar risk remains uncertain.

Case presentation

We presented the case of a 55-year-old Chinese woman diagnosed with MDD and anxious distress. After receiving various types of antidepressants, she experienced hematochezia following the administration of tandospirone, sertraline, and agomelatine. The occurrence of hematochezia ceased after tandospirone was discontinued. The patient was subsequently discharged with a treatment regime consisting of sertraline and agomelatine. During the 1-month follow-up, she reported no hematochezia.

Conclusion

Tandospirone may potentially increase the risk of hematochezia in patients with MDD and anxious distress.

Potential drug-drug interactions in adults receiving oral anticoagulant and antiaggregant therapy

BACKGROUND

Anticoagulant and antiaggregant drugs are drug groups with high mortality and the most common cause of malpractice.

RESEARCH DESIGN AND METHODS

18 and 65 years were scheduled for pharmacotherapy in the Family Health Center. 122 patients during their anticoagulant and/or antiaggregant treatment were evaluated in terms of drug-drug interactions.

RESULTS

Drug-drug interactions were detected in 89.7% of the patients included in the study. A total of 212 drug-drug interactions were found in 122 patients. Of these, 12 (5.6%) were identified as A, 16 (7.5%) B, 146 (68.6%) C, 32 (15.2%) D and 6 (2.8%) X risk category. The number of DDI was found to be significantly higher in patients aged between 56 and 65 years. The most drug interactions are significantly higher in the C and D categories, respectively. The most predicted clinical outcomes of DDI's were increased in the therapeutic effect and adverse/toxic reactions.

CONCLUSIONS

Contrary to expectations, it is seen that although polypharmacy is relatively less in patients aged 18-65 years compared to patients over 65 years of age, it is very important to detect drug interactions in this age group in terms of safety, efficacy and treatment benefit in terms of drug-drug interaction.

Risk of Gastrointestinal Bleeding with Concurrent Use of NSAID and SSRI: A Systematic Review and Network Meta-Analysis

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.

Strategies for Avoiding Typical Drug-Drug Interactions and Drug-Related Problems in Patients with Vascular Diseases

Background and objectives: Drug-drug interactions and drug-related problems in patients with vascular diseases are common. To date, very few studies have focused on these important problems. The aim of the present study is to investigate the most common drug-drug interactions and DRPs in patients with vascular diseases. Materials and Methods: The medications of 1322 patients were reviewed manually in the time period from 11/2017 to 11/2018; the medications of 96 patients were entered into a clinical decision support system. Potential drug problems were identified, and a read-through consensus was reached between a clinical pharmacist and a vascular surgeon during the clinical curve visits; possible modifications were implemented. The focus was on additional dose adjustment and drug antagonization on drug interactions. Interactions were classified as contraindicated/high-risk combination (drugs must not be combined), clinically serious (interaction can be potentially life-threatening or have serious, possibly irreversible consequences), or potentially clinically relevant and moderate (interaction can lead to therapeutically relevant consequences). Results: A total of 111 interactions were observed. Of these, 6 contraindicated/high-risk combinations, 81 clinically serious interactions, and 24 potentially clinically relevant and moderate interactions were identified. Furthermore, 114 interventions were recorded and categorized. Discontinued use of the drug (36.0%) and drug dose adjustment (35.1%) were the most common interventions. Mostly, antibiotic therapy was continued unnecessarily (10/96; 10.4%), and the adjustment of the dosage to kidney function was overlooked in 40/96; 41.7% of the cases. In the most common cases, a dose reduction was not considered necessary. Here, unadjusted doses of antibiotics were found in 9/96, 9.3% of the cases. Notes for medical professionals summarized information that did not require direct intervention but rather increased attention on the part of the ward doctor. It was usually necessary to monitor laboratory parameters (49/96, 51.0%) or the patients for side effects (17/96, 17.7%), which were expected with the combinations used. Conclusions: This study could help identify problematic drug groups and develop prevention strategies for drug-related problems in patients with vascular diseases. A multidisciplinary collaboration between the different professional groups (clinical pharmacists and surgeons) might optimize the medication process. Collaborative care could have a positive impact on therapeutic outcomes and make drug therapy safer for patients with vascular diseases.

Major Adverse Cardiovascular Events in Antidepressant Users Within Patients With Ischemic Heart Diseases: A Nationwide Cohort Study

BACKGROUND

To evaluate the effect of antidepressants on the development of major adverse cardiovascular events (MACEs) in patients with ischemic heart disease (IHD), we analyzed the association between antidepressant use and the risk of MACE development.

METHODS

Patients with depression and a history of IHD between 2008 and 2012 were identified by using the National Health Insurance Service database. A cohort was followed up for the development of MACE until the end of 2015. Hazard ratios (HRs) for myocardial infarction, stroke, and cardiovascular death were estimated by Cox proportional hazard regression in a propensity score-matched cohort.

RESULTS

Over a median 4.2 years of follow-up, 2943 MACE occurred in 18,981 antidepressant users. Use of antidepressants was not associated with the incidence of MACE when compared with antidepressant nonusers (adjusted HR, 1.00; 95% confidence interval, 0.95-1.05). Among the analyses according to different classes of antidepressants, the increased risk of stroke was only observed in the subgroup of selective serotonin reuptake inhibitor (SSRI) users. Dose-response findings reported greater risk in those with higher doses of use (SSRIs with ≥1.0 defined daily dose; adjusted HR, 1.14; 95% confidence interval, 1.06-1.23), whereas duration response does not support association.

CONCLUSIONS

Compared with antidepressant nonusers, use of antidepressants was not associated with occurrence of MACEs in patients with depression and IHD. Although the overall effect of antidepressants on the risk of MACE was neutral, careful monitoring of MACE development is recommended in high-dose SSRI users.

Selective Serotonin Reuptake Inhibitor Use and Risk of Gastrointestinal and Intracranial Bleeding

Selective serotonin reuptake inhibitors (SSRIs) are among the most commonly prescribed medications in the United States. Although SSRIs are highly tolerable relative to other antidepressants, they are associated with a number of adverse effects, including increased gastrointestinal tract bleeding and intracranial bleeding. Mechanisms include increased gastric acid secretion and inhibition of serotonin entrance into platelets. Patients with other bleeding risk factors, such as warfarin, clopidogrel, or aspirin use, may be at heightened risk of these adverse effects. The purpose of this article is to review the incidence of gastrointestinal tract bleeding or intracranial bleeding associated with concomitant SSRI use, the proposed mechanisms of, and the potential pharmacokinetic/pharmacodynamic interactions with anticoagulants and antiplatelets. Given the prevalence of SSRI use in the ambulatory setting, osteopathic physicians should be aware of potential drug-drug interactions and the clinical implications of SSRI-associated bleeding risk.

5-Hydroxytryptamine Changes under Different Pretreatments on Rat Models of Myocardial Infarction and/or Depression

Background:

Psychocardiological researches have suggested a central role of 5-hydroxytryptamine (5-HT) on psychocardiological mechanism. This study aimed to further explore the central role of 5-HT and pretreatment effects of XinLingWan on rats with myocardial infarction (MI) and/or depression.

Methods:

Ninety Sprague-Dawley rats were randomly divided into three groups: MI group, depression group, and MI + depression group (n = 30 in each group). Each group was then divided into three subgroups (n = 10 in each subgroup): a negative control subgroup (NCS), a Western medicine subgroup (WMS), and a traditional Chinese medicine subgroup (TCMS), which were received pretreatment once a day for 4 weeks by saline, 20 mg/kg sertraline mixed with 2 ml saline, and 40 mg/kg XingLingWan mixed with 2 ml saline, respectively. Different rat models were established after different pretreatments. Rats were then sacrificed for detection of serum 5-HT, platelet 5-HT, 5-HT_2A receptors (5-HT_2AR), and serotonin transporter (SERT). Data were analyzed by one-way analysis of variance (ANOVA) and least-significant difference (LSD) testing.

Results:

MI group: compared with NCS, there was a significant increase in WMS and TCMS of serum 5-HT (176.15 ± 11.32 pg/ml vs. 334.50 ± 29.09 pg/ml and 474.04 ± 10.86 pg/ml, respectively, both P = 0.000), platelet 5-HT (129.74 ± 27.17 pg/ml vs. 322.24 ± 11.60 pg/ml and 340.4 5 ± 17.99 pg/ml, respectively, both P = 0.000); depression group: compared with NCS, there was a significant increase in WMS and TCMS of serum 5-HT (194.69 ± 5.09 pg/ml vs. 326.21 ± 39.98 pg/ml and 456.33 ± 23.12 pg/ml, respectively, both P = 0.000), platelet 5-HT (175.15 ± 4.07 pg/ml vs. 204.56 ± 18.59 pg/ml and 252.03 ± 22.26 pg/ml, respectively, P = 0.004 and P = 0.000, respectively); MI + depression group: compared with NCS, there was a significant increase in both WMS and TCMS of serum 5-HT (182.50 ± 10.23 pg/ml vs. 372.55 ± 52.23 pg/ml and 441.76 ± 23.38 pg/ml, respectively, both P = 0.000) and platelet 5-HT (180.83 ± 11.08 pg/ml vs. 221.12 ± 22.23 pg/ml and 265.37 ± 29.49 pg/ml, respectively, P = 0.011 and P = 0.000, respectively).

Conclusions:

By elevating the amount of 5-HT and modulating 5-HT_2AR and SERT levels in serum and platelets, XinLingWan and sertraline were found to exert pretreatment effect on rat models of MI and/or depression.

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

Risk of Bleeding in Patients on Full-Dose Enoxaparin With Venous Thromboembolism and Selective Serotonin Reuptake Inhibitors

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are very commonly prescribed agents that are also potent antiplatelet agents.

OBJECTIVE

This study was designed compare the rate of major bleeding events between patients who were treated with low-molecular-weight heparin (LMWH) for venous thromboembolism (VTE) on SSRIs and those not on chronic SSRI therapy.

METHODS

This was a retrospective cohort study of 575 patients with a primary or secondary diagnosis of an acute VTE initiated on full-dose enoxaparin with or without an SSRI between October 1, 2009, and October 1, 2014, in a 443-bed, single tertiary care referral county teaching hospital.

RESULTS

No significant difference was found in the incidence of major bleeding in the SSRI versus non-SSRI group (19.6% vs 17.0%, P = 0.548). Ad hoc analysis demonstrated an elevated risk of major bleeding in patients on escitalopram compared with those on any of the other SSRIs (46.2% vs 15.2%, P = 0.018). Multivariate analysis demonstrated that escitalopram use-OR (95% CI) = 18.85 (1.84-193.6)-was associated with increased major bleeding, and acid suppressive therapy-0.24 (0.07-0.90); P = 0.014-was associated with decreased major bleeding in patients reporting alcohol use.

CONCLUSION

No difference was found in the incidence of major bleeding in patients on LMWH and SSRIs versus those on LMWH but not on SSRIs. However, ad hoc findings showed a significantly higher rate of major bleeding events in patients who received escitalopram and alcohol among patients on full-dose enoxaparin for VTE. These findings merit further exploration.

Pharmacovigilance during ibrutinib therapy for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) in routine clinical practice

Due to Cytochrome P450 3A (CYP3A) metabolism, clinical trials of ibrutinib-treated chronic lymphocytic leukemia (CLL) patients prohibited concurrent medications metabolized by CYP3A. We evaluated concomitant medication use in 118 ibrutinib-treated CLL patients outside the context of clinical trials. Seventy-five (64%) patients were on medications that could increase ibrutinib toxicity and 4 (3%) were on drugs that could decrease ibrutinib efficacy. Nineteen (16%) patients were on concomitant CYP3A inhibitors (11 moderate, 8 strong), and 4 (3%) were on CYP3A inducers (two patients were on both CYP3A inhibitors and inducers). Although the ibrutinib starting dose was changed in 18 patients on CYP3A interacting medications, no difference in 18-month progression-free survival or rate of ibrutinib discontinuation was observed in patients who were not. In routine clinical practice, 2 of 3 CLL patients commencing ibrutinib are on a concomitant medication with potential to influence ibrutinib metabolism. Formal medication review by a pharmacist should be considered in all patients initiating ibrutinib.

Bleeding risk under selective serotonin reuptake inhibitor (SSRI) antidepressants: A meta-analysis of observational studies

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.

Vortioxetine : a review of efficacy, safety and tolerability with a focus on cognitive symptoms in major depressive disorder

INTRODUCTION

Vortioxetine is a pharmacodynamically novel antidepressant that exerts effects on various neurotransmitters including serotonin, noradrenaline, dopamine, glutamate, histamine and acetylcholine. Its efficacy in the symptomatic management of major depressive disorder (MDD) has been established in several short- and long-term trials. Vortioxetine has also demonstrated independent pro-cognitive effects in adults with MDD.

AREAS COVERED

This report provides a concise review of the pharmacology, efficacy and safety of vortioxetine as they pertain to cognition.

EXPERT OPINION

The significant impact of cognitive dysfunction in MDD has achieved increased consideration among researchers over the past decade. Vortioxetine is the first antidepressant agent to demonstrate meaningful clinical efficacy in the improvement of cognition in adults with MDD, independent of improvement in affective symptomatology. These results provide the impetus for further study into the potential pro-cognitive effects of vortioxetine in other conditions wherein cognitive dysfunction is prominent.

Health disparities among workers and nonworkers with functional limitations: implications for improving employment in the United States

PURPOSE

The aim of this study was to compare workers and nonworkers who reported mild, moderate, and severe/complete functional limitations to identify disparities in 19 health and social indicators.

METHOD

Using the International Classification of Functioning, Disability and Health as our conceptual framework, we analyzed data from the combined 2000-2008 National Health Interview Survey, comparing workers and nonworkers by severity of functional limitations, as measured by the FL12 Scale of Functional Limitation Severity.

RESULTS

Only 9.5% of people reporting moderate/severe functional limitations worked. Although not without exception, not working and severity of functional limitation were associated with poorer health outcomes, with nonworkers reporting severe/complete limitations having least optimal health. Prevalence of chronic conditions was associated with level of functional limitation severity, with the strongest associations among nonworkers.

CONCLUSIONS

By focusing exclusively on people with functional limitations, we were better able to examine factors contributing to health and participation of workers and nonworkers. People who worked and had moderate or severe/complete limitations often did so while reporting poor health. With improved access to health care, health promotion activities, and other support systems, the quality of life and likelihood of work participation of people with greater functional limitations might also be improved.

Selective Serotonin Reuptake Inhibitor (SSRI) Antidepressants, Prolactin and Breast Cancer

Selective serotonin reuptake inhibitors (SSRIs) are a widely prescribed class of antidepressants. Laboratory and epidemiologic evidence suggests that a prolactin-mediated mechanism secondary to increased serotonin levels at neuronal synapses could lead to a potentially carcinogenic effect of SSRIs. In this population-based case-control study, we evaluated the association between SSRI use and breast cancer risk as a function of their relative degree of inhibition of serotonin reuptake as a proxy for their impact on prolactin levels. Cases were 2,129 women with primary invasive breast cancer diagnosed from 2003 to 2007, and controls were 21,297 women randomly selected from the population registry. Detailed information for each SSRI prescription dispensed was compiled using the Saskatchewan prescription database. Logistic regression was used to evaluate the impact of use of high and lower inhibitors of serotonin reuptake and duration of use, as well as to assess the effect of individual high inhibitors on the risk of breast cancer. Exclusive users of high or lower inhibitors of serotonin reuptake were not at increased risk for breast cancer compared with non-users of SSRIs (OR = 1.01, CI = 0.88–1.17 and OR = 0.91, CI = 0.67–1.25 respectively), regardless of their duration of use or menopausal status. While we cannot rule out the possibility of a clinically important risk increase (OR = 1.83, CI = 0.99–3.40) for long-term users of sertraline (≥24 prescriptions), given the small number of exposed cases (n = 12), the borderline statistical significance, and the wide confidence interval, these results need to be interpreted cautiously. In this large population-based case-control study, we found no conclusive evidence of breast cancer risk associated with the use of SSRIs even after assessing the degree of serotonin reuptake inhibition and duration of use. Our results do not support the serotonin-mediated pathway for the prolactin-breast cancer hypothesis.

[Perioperative adverse events related to antidepressive agents use]

OBJECTIVE

Depression is the most common psychiatric disease, which is treated by the use of antidepressive agents possessing various mechanisms of action. Thus, the use in preoperative period of antidepressive agents is frequent (7% of patients scheduled for surgery). The objective of this review was to update the knowledge on the drug interactions between antidepressive agents and drugs used in perioperative period.

METHODS

(i) Medline and Ovid databases using combination of antidepressive agent and perioperative period as keywords; (ii) national and European epidemiologic database; (iii) expert recommendation and official French health agency; (iv) reference book chapters.

RESULTS

The clinical practice showed a limited risk of adverse event related to antidepressant agents interaction with perioperative used drugs. In the two past decades, few relevant observations of adverse event related with imipramine and monoamine oxidase inhibitors use was reported. The most recent antidepressive agents had no serious adverse interaction. Nevertheless, the serotonin syndrome has to be known as far as it is more and more reported. In case of hypotension, the use of vasopressive agent has to be careful because of excessive response.

Antiplatelet drug interactions

Both laboratory studies in healthy volunteers and clinical studies have suggested adverse interactions between antiplatelet drugs and other commonly used medications. Interactions described include those between aspirin and ibuprofen, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), and the thienopyridine, clopidogrel, and drugs inhibiting CYP2C19, notably the proton pump inhibitors (PPI) omeprazole and esomeprazole. Other interactions between thienopyridines and CYP3A4/5 have also been reported for statins and calcium channel blockers. The ibuprofen/aspirin interaction is thought to be caused by ibuprofen blocking the access of aspirin to platelet cyclo-oxygenase. The thienopyridine interactions are caused by inhibition of microsomal enzymes that metabolize these pro-drugs to their active metabolites. We review the evidence for these interactions, assess their clinical importance and suggest strategies of how to deal with them in clinical practice. We conclude that ibuprofen is likely to interact with aspirin and reduce its anti-platelet action particularly in those patients who take ibuprofen chronically. This interaction is of greater relevance to those patients at high cardiovascular risk. A sensible strategy is to advise users of aspirin to avoid chronic ibuprofen or to ingest aspirin at least 2 h prior to ibuprofen. Clearly the use of NSAIDs that do not interact in this way is preferred. For the clopidogrel CYP2C19 and CYP3A4/5 interactions, there is good evidence that these interactions occur. However, there is less good evidence to support the clinical importance of these interactions. Again, a reasonable strategy is to avoid the chronic use of drugs that inhibit CYP2C19, notably PPIs, in subjects taking clopidogrel and use high dose H2 antagonists instead. Finally, anti-platelet agents probably interact with other drugs that affect platelet function such as selective serotonin reuptake inhibitors, and clinicians should probably judge patients taking such combination therapies as at high risk for bleeding.

[SSRI - treatment and bleeding. What risks do we take?]

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.

On categorizing gestational, birth, and neonatal complications following late pregnancy exposure to antidepressants: the prenatal antidepressant exposure syndrome

INTRODUCTION

Late in utero exposure to antidepressants has been suspected of adversely impacting pregnancy outcome and compromising neonatal adaptation. Hence, the necessity exists to analyze published information on antidepressant use during late pregnancy to individuate potential recurrent patterns of iatrogenic complications.

METHODS

Computerized searches on MEDLINE, PsycINFO, ENBASE, and Cochrane Library through February 10, 2010 were performed for selecting literature information and investigating the safety of antidepressants when used during late pregnancy.

RESULTS

Antidepressant treatment during late pregnancy may increase the rates of poor pregnancy outcome and neonatal withdrawal/toxic reactions.

CONCLUSIONS

Because both gestational complications and neonatal adverse events acknowledge the same etiology, the author suggests including such iatrogenic events under the definition of prenatal antidepressant exposure syndrome, in order to increase clinicians' awareness about the spectrum of risks which may concern the mother-infant pair when antidepressant treatment is deemed indispensable during late pregnancy.

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

BACKGROUND

Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice.

METHODS

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008.

RESULTS

Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks.

CONCLUSIONS

Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

How I treat age-related morbidities in elderly persons with hemophilia

In persons with hemophilia, life expectancy is now approaching that of the general male population, at least in countries that can afford regular replacement therapy with coagulation factor concentrates. The new challenges for comprehensive treatment centers are thus to provide optimal health care for this aging population of patients, who often present not only with the comorbidities typically associated with hemophilia (arthropathy, chronic pain, blood-borne infections), but also with common age-related illnesses such as cardiovascular disease and cancer. There are no evidence-based guidelines for the management of these conditions, which often require drugs that interfere with hemostasis, enhance the bleeding tendency, and warrant more intensive replacement therapy. At the moment, elderly patients with hemophilia affected by other diseases should be managed like their age-group peers without hemophilia, provided replacement therapy is tailored to the heightened risk of bleeding associated with the need for invasive procedures and drugs that further compromise the deranged hemostasis. More detailed advice is provided on the schedules of replacement therapy needed to tackle cardiovascular diseases, such as acute coronary syndromes and nonvalvular atrial fibrillation, because these conditions will become more and more frequent challenges for the comprehensive treatment centers.

Problems associated with long-term treatment with selective serotonin reuptake inhibitors

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.

Risk of clinically relevant bleeding in warfarin-treated patients--influence of SSRI treatment

PURPOSE

To investigate the risk of clinically relevant bleeding in warfarin-treated patients with or without concomitant treatment with selective serotonin reuptake inhibitors (SSRIs).

METHODS

A cohort study was performed in patients treated with warfarin due to atrial fibrillation. Exposed patients were defined as patients treated with SSRI at any time between January 1999 and September 2005 (n = 117). Unexposed patients without SSRI-treatment were randomly selected and matched for age and sex (1:1). The primary endpoint was hospital admission due to bleeding during the same time period.

RESULTS

Bleeding occurred in 17 exposed patients (totally 23 bleedings) and in two unexposed patients (totally two bleedings) (p = 0.0003). A total of 11 bleedings occurred during treatment with the combination of warfarin and SSRI, and 14 during treatment with warfarin only. The total incidences of bleedings per 1000 treatment years were 51.4 (25.7-92.0) and 23.9 (13.1-40.1), respectively, and the unadjusted incidence rate ratio (IRR) 2.15 (0.88-5.11). Cox regression analysis including first bleedings revealed an adjusted hazard ratio of 3.49 (1.37-8.91) for bleeding during treatment with a combination of SSRI and warfarin compared with treatment with warfarin only. Initiation of SSRI therapy was not associated with a change in dose of warfarin or with a change in international normalized ratio (INR) (p = 0.48 and p = 0.31, respectively).

CONCLUSION

Addition of SSRI to warfarin-treated patients may be associated with an increased risk of clinically relevant bleeding. The effect seems not to be associated with a direct influence of SSRI on the anti-coagulant activity of warfarin.

Occurrence, course and risk factors of depression during antiviral treatment for chronic hepatitis C in patients with inherited bleeding disorders: a prospective study

Treatment of hepatitis C virus (HCV) consists of pegylated interferon (IFN)-alpha and ribavirin for 24 or 48 weeks. An important side-effect of IFN-alpha is depression. The occurrence, course and risk factors of depression during antiviral treatment were studied prospectively in HCV patients with inherited bleeding disorders. The Beck Depression Inventory, indicating no, mild, moderate or severe depression, was administered to 47 patients before starting therapy, after 4, 12, 24 and 48 weeks of treatment, and 4 weeks after cessation of therapy. At baseline, five patients (11%) had mild depression. Depression worsened during treatment in three of these patients. In all five patients, (mild) depression persisted 4 weeks after treatment. Of the remaining 42 patients, 23 (55%) developed depression during treatment (14 mild, eight moderate and one severe), mostly (78%) during the first 12 weeks. Four weeks after cessation of treatment, three of 23 patients still had mild depression. The only independent risk factor for development of depression was a history of depression or other psychiatric problems (odds ratio 9.7). For patients with inherited bleeding disorders, depression is a significant, mostly transient, problem during HCV treatment. We recommend close monitoring of patients, especially those with previous psychiatric problems, to ensure adequate detection and treatment of depression during antiviral therapy.

[Dermatological side effects during therapy with serotonin noradrenaline reuptake inhibitors]

Bleeding complications during therapy with serotonin norepinephrine reuptake inhibitors are a well-known phenomenon. We report a patient who developed ecchymosis during administration of duloxetine. As a correlate we detected a transient platelet dysfunction. After converting to venlafaxine therapy, another antidepressant with a dual mechanism of action, the patient showed normal platelet function. We finally achieved remission of the episode.

Multiple health disparities among minority adults with mobility limitations: san application of the ICF framework and codes

PURPOSE

To examine the interface between mobility limitations and minority status and its effect on multiple health and health-related domains among adults, using the framework of the International Classification of Functioning, Disability and Health (ICF).

METHODS

We combined 8 years of data from the 1997-2004 US National Health Interview Survey to investigate health disparities among minorities with mobility limitations as defined by the ICF. A total of 79,739 adults surveyed met these criteria.

RESULTS

Adults with both mobility limitations and minority status experienced the greatest disparities (p<0.001) in worsening health (adjusted odds ratio [AOR]=8.5), depressive symptoms (AOR=17.2), diabetes (AOR=5.5), hypertension (AOR=3.4), stroke (AOR=7.2), visual impairment (AOR=4.6), difficulty with activities of daily living (AOR=42.7) and instrumental activities of daily living (AOR=27.7), use of special equipment (AOR = 28.1), obesity (AOR=3.3), physical inactivity (AOR=2.7), and low workforce participation (AOR=0.35).

CONCLUSIONS

For most outcome measures, findings supported our hypothesis that persons with both mobility limitations and minority status experience greater health disparities than do adults with minority status or mobility limitations alone.

Hematologic problems in psychosomatic medicine

Vitamin B12 deficiency is associated with problems in cognition, mood, psychosis, and less commonly, anxiety. Folate deficiency primarily is associated with problems in mood. Patients who have sickle cell disease, a disease of chronic pain, experience difficulties with depression, anxiety, stigma, and are at risk for substance abuse and dependence. Patients with hemophilia have benefited from advances in treatment; however, their morbidity and mortality were compounded in those who received blood products contaminated with HIV, or hepatitis B and C. Psychiatrists who practice psychosomatic medicine should expect to encounter patients with the above problems, as they are frequently seen in medical settings. Finally, most of the commonly used psychotropic medications have uncommon but potentially important hematologic side effects or may interact with the anticoagulants used in medically ill patients.