Reducing bleeding risk with SSRIs: some recommendations

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Takeaway

  • Selective serotonin reuptake inhibitors (SSRIs) are tied to increased bleeding risk.
  • These authors have surveyed relevant meta-analyses to develop recommendations for managing and reducing the risk.

Why this matters

  • Antidepressants are commonly prescribed, and SSRIs in particular may affect platelets.

Study design

  • Nonsystematic review of 9 meta-analyses of bleeding risk with SSRIs and 1 meta-analysis of bleeding risk with mirtazapine (Remeron) and bupropion (Zyban).
  • Funding: None.

Highlights

  • The risk for any bleed was heightened with SSRI use: OR, 1.41 (P<.001>
  • The risk was particularly high for gastrointestinal bleeding: OR, 1.55 (95% CI, 1.32-1.82).
  • Risk was lower for intracranial hemorrhage: OR, 1.16 (95% CI, 1.01-1.33).
  • One meta-analysis showed increased risk for brain hemorrhage associated with SSRI use: OR, 1.61 (95% CI, 1.04-2.51). 
  • Another showed greater risk for postpartum hemorrhage: OR, 1.32 (P<.001>
  • With respect to concomitant drugs, the researchers found increased risk associated with use of NSAIDs, with ORs ranging from 3.17 to 10.9.

Recommendations

  • When prescribing SSRIs, clinicians must ask patients about over-the-counter drug use, especially NSAIDs.
  • For at-risk patients, education about bleeding risk is critical.
  • Bupropion may be a good choice for at-risk patients.
  • Proton-pump inhibitors may reduce bleeding risk, but their adverse effects must be considered.