Clinical Management of Bleeding Risk With Antidepressants

Bixby, Alexandra L; VandenBerg, Amy; Bostwick, Jolene R.

doi:10.1177/1060028018794005

Cited by 45 publications

(37 citation statements)

References 44 publications

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“…This raises the possibility that addressing target symptoms such as psychosis or agitation related to depression and CBVD might be associated with benefits that outweigh potential risks; however, this clearly requires further investigation. Although mirtazapine has also been associated with a more benign cardiovascular risk profile36 and less blood-thinning effects than SSRIs,37 thus theoretically reducing risk of further haemorrhagic stroke, we found no evidence of a significant association in our cohort. However, antidepressants were not significantly associated with higher risk of stroke recurrence, consistent with a previous study 9.…”

Section: Discussioncontrasting

confidence: 77%

Predictors of cerebrovascular event reoccurrence in patients with depression: a retrospective cohort study

et al. 2020

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ObjectivesTo identify predictors of recurrent cerebrovascular morbidity in a cohort of patients with depression and a cerebrovascular disease (CBVD) history.MethodsWe used the Maudsley Biomedical Research Centre Case Register to identify patients aged 50 years or older with a diagnosis of depressive disorder between 2008 and 2017 and a previous history of hospitalised CBVD. Using depression diagnosis as the index date we followed patients until first hospitalised CBVD recurrence or death due to CBVD. Sociodemographic data, symptom and functioning scores of Health of the Nation Outcome Scales, medications and comorbidities were extracted and modelled in multivariate survival analyses to identify predictors of CBVD reoccurrence.ResultsOf 1292 patients with depression and CBVD (mean age 75.6 years; 56.6% female), 264 (20.4%) experienced fatal/non-fatal CBVD recurrence during a median follow-up duration of 1.66 years. In multivariate Cox regression models, a higher risk of CBVD recurrence was predicted by older age (HR, 1.02; 95% CI, 1.01 to 1.04) (p=0.002), physical health problems (moderate to severe HR, 2.47; 95% CI, 1.45 to 4.19) (p=0.001), anticoagulant (HR, 1.40; 95% CI, 1.01 to 1.93) (p=0.041) and antipsychotic medication (HR, 0.66; 95% CI 0.44 to 0.99) (p=0.047). Neither depression severity, mental health symptoms, functional status, nor antidepressant prescribing were significantly associated with CBVD recurrence.ConclusionsApproximately one in five patients with depression and CBVD experienced a CBVD recurrence over a median follow-up time of 20 months. Risk of CBVD recurrence was largely dependent on age and physical health rather than on severity of depressive symptoms, co-morbid mental health or functional problems, or psychotropic prescribing.

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Section: Discussioncontrasting

confidence: 77%

Predictors of cerebrovascular event reoccurrence in patients with depression: a retrospective cohort study

et al. 2020

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“…We did not find evidence of other differences in the hazard of bleeding associated with antidepressant initiation by specific OAC type, sex, or age. Both OAC and certain types of antidepressants are associated with an increased risk of bleeding [23][24][25]. Previous studies have reported the association of antidepressant use with bleeding risk in OAC users.…”

Section: Discussionmentioning

confidence: 99%

“…Both OAC and certain types of antidepressants are associated with an increased risk of bleeding [ 23 – 25 ]. Previous studies have reported the association of antidepressant use with bleeding risk in OAC users.…”

Section: Discussionmentioning

confidence: 99%

Association of Type of Antidepressant Initiation with Bleeding Risk in Atrial Fibrillation Patients Taking Oral Anticoagulants

Shao

Claxton

Lutsey

et al. 2021

Drugs - Real World Outcomes

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Background Inconsistent evidence suggests that use of certain antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), in patients using oral anticoagulants (OACs) might be associated with an elevated risk of bleeding. Objective This study aims to investigate the risk of bleeding associated with initiation of different types of antidepressants among atrial fibrillation (AF) patients on OAC therapy. Patients and methods A total of 30,336 AF patients (mean age 72.2 years; 54% female) on OAC therapy that started antidepressant treatment were identified from the Truven Health Analytics MarketScan Commercial and Medicare Databases for the period 2007-2015. Exposure was defined as filling a prescription for antidepressant, and categorized as SSRI, serotonin/ norepinephrine reuptake inhibitors (SNRIs), serotonin reuptake inhibitors (SRIs), tricyclic antidepressants (TCAs), or other antidepressants. The primary outcome was incident hospitalized bleeding. Associations of antidepressant type with bleeding were assessed calculating hazard ratios (HRs) and 95% confidence intervals (CIs) with adjusted Cox models in pairwise propensity score-matched cohorts. Results During a mean follow-up of 21 months, we identified 1612 bleeding episodes. In pairwise comparisons, SSRI use was associated with an increased risk of bleeding when compared to most other antidepressants (HR 1.22, 95% CI 0.96-1.54 vs SNRI; HR 1.10, 95% CI 0.90-1.35 vs SRI; HR 1.03, 95% CI 0.82-1.30 vs TCA). SNRI use was associated with the lowest bleeding risk. Results did not differ by OAC type, age, and sex. Conclusions Among AF patients on OAC initiating antidepressants, risk of bleeding varied across antidepressant type. This information can inform treatment choices among patients receiving OAC.

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“…A clear reduction in both prescribed doses, mean serum concentration and the proportion of patients with serum concentrations above the recommended reference range was observed for mirtazapine. Mirtazapine is an atypical antidepressant with a considerable sedative effect prominent in low-dose regimens, and, because of its distinctive receptor profile and anticipated lower risk of adverse drug reactions such as hyponatremia and bleeding, mirtazapine is a frequently used comedication with other antidepressants and might also be a preferred antidepressant in patients with considerable comorbidity and polypharmacy [28][29][30][31]. The prominent reduction in the proportion of individuals with serum concentrations above the recommended reference range observed in our study may imply a reduced risk of adverse effects in these patients.…”

Section: Discussionmentioning

confidence: 99%

Use of Antidepressants in Older People during a 10-Year Period: An Observational Study on Prescribed Doses and Serum Levels

et al. 2020

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Background According to previous studies, older patients frequently have serum concentrations of antidepressant medication above the recommended reference range. Objective The aim of this study was to investigate whether prescribed doses of antidepressants and the proportion of individuals with serum concentrations above the recommended reference range in older individuals (≥ 65 years) have changed over a 10-year period in Norway. Methods Serum concentration measurements and prescribed daily doses of antidepressants in 2007 and 2017 were extracted from a therapeutic drug monitoring (TDM) database at the Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway. The database contains routine follow-up serum concentration measurements of psychotropic drugs for patients from all parts of the country. For citalopram, escitalopram, sertraline, mirtazapine and venlafaxine, the differences between 2007 and 2017 in mean prescribed doses and the proportion of patients with at least one serum concentration above the reference range, according to the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) guidelines, were compared. For the proportion of patients with serum concentrations above the recommended reference range, differences between individuals aged 65-79 and ≥ 80 years were also examined. Results The analyses of prescribed doses included 806 patients from 2007 and 1932 patients from 2017, with 972 and 2441 TDM samples, respectively. Between 2007 and 2017, modest reductions in prescribed daily doses were observed for citalopram (20 vs. 17 mg/day) and escitalopram (11 vs. 10 mg/day), but the proportion of patients with serum concentrations above the recommended reference range was unchanged for both drugs, i.e. 11.5% vs. 12.4% for citalopram and 3.6% vs. 2.9% for escitalopram. For mirtazapine and venlafaxine, prescribed doses were reduced from 28 to 25 mg/day and 150 to 125 mg/day, respectively. A significant reduction in the proportion of individuals with serum concentrations above the recommended reference range was observed for mirtazapine (27.1% vs. 11.5%) and for individuals aged ≥ 80 years using venlafaxine (60.0% vs. 30.0%). For sertraline, no differences in prescribed doses or serum concentrations above the recommended reference range were observed. Conclusions Over a 10-year period, prescribed doses of antidepressants have been slightly reduced in older Norwegian patients, but a considerable proportion is still exposed to high serum concentrations of antidepressants.

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Clinical Management of Bleeding Risk With Antidepressants

Abstract: Clinicians must be aware of the risk of bleeding with SRI use, especially for patients taking NSAIDs. Patient education is prudent for those prescribed NSAIDs and SRIs concurrently.

Cited by 45 publications

References 44 publications

Predictors of cerebrovascular event reoccurrence in patients with depression: a retrospective cohort study

Predictors of cerebrovascular event reoccurrence in patients with depression: a retrospective cohort study

Association of Type of Antidepressant Initiation with Bleeding Risk in Atrial Fibrillation Patients Taking Oral Anticoagulants

Use of Antidepressants in Older People during a 10-Year Period: An Observational Study on Prescribed Doses and Serum Levels

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