Table
Risk factors for gastrointestinal bleeding
| Medications | Corticosteroids, anticoagulants (warfarin), antiplatelets (clopidogrel), NSAIDs (including aspirin), calcium channel blockers, SSRIs, SNRIs, tricyclic antidepressants |
| Disease state/patient factors | Age (elderly are at higher risk), history of ulcer, chronic alcohol use, peptic ulcer disease, esophageal varices, gastric or colorectal cancer, gastritis, liver disease, coagulopathy |
| NSAIDs: nonsteroidal anti-inflammatory drugs; SNRIs: serotonin-norepinephrine reuptake inhibitors; SSRIs: selective serotonin reuptake inhibitors | |
| Source: References 2-5 | |
Reducing bleeding risk
In a case-control study, de Abajo et al4 found that patients taking acid-suppressing drugs—proton pump inhibitors and histamine H2 receptor antagonists—had a lower risk of upper GI tract bleeding associated with serotonergic antidepressants compared with those not taking acid-suppressing medications. These drugs further reduced the risk of bleeding in patients taking NSAIDs or antiplatelet medications concomitantly with SSRIs. We suggest initiating prophylactic acid suppression therapy for any patient who is considered at high risk for a GI bleed and is taking an SSRI with or without other medications that inhibit platelet aggregation. Specifically, start with an H2 antagonist because of these medications’ faster onset of action and lower cost vs proton pump inhibitors.
Although the association between SSRIs and bleeding have been described in observational studies, it is impossible to rule out alternate causes and potential confounders that may have contributed to these events. Due diligence and therapeutic drug monitoring of all known and predicted drug-drug interactions is warranted for all patients taking serotonergic antidepressants in combination with medications known to increase bleeding risk.
Related Resources
- Indiana University School of Medicine. P450 drug interaction table. http://medicine.iupui.edu/clinpharm/ddis/table.asp.
- Hansten PD, Horn JR. The top 100 drug interactions: a guide to patient management. Edmonds, WA: H&H Publications; 2010.
Drug Brand Names
- Bupropion • Wellbutrin
- Citalopram • Celexa
- Clopidogrel • Plavix
- Lisinopril • Zestril, Prinivil
- Simvastatin • Zocor
- Warfarin • Coumadin
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.