SSRI and the Risk of Gastrointestinal Bleed: More than What Meets the Eye

Abstract

We read with interest the meta-analysis about selective serotonin reuptake inhibitors (SSRIs) and their association with upper gastrointestinal bleed (GIB) ( 1 ). We had reported results on the same topic at Digestive Diseases Week in 2012 ( 2 ) and it is heartening to know that the results of the published meta-analysis are similar, despite slight diff erences in study selection. Th rough this letter, we will like to highlight certain aspects of literature that may contribute to the ongoing discussion of this important topic.We propose that two more case-control studies ( 3,4 ) with additional 53,969 patients (10,199 cases and 43,770 controls) can be added to this meta-analysis, thus increasing the total number of participants from 393,268 to 447,237. Since the odds ratio for GIB in these two studies was around 1.3 (as compared to 1.66 reported by authors), if these studies are included, the risk of GIB with SSRIs would be lower albeit still signifi cant.We would like to draw readers' attention to the fact that most of the studies in metaanalysis excluded patients with a history of previous GIB. Th e number needed to harm (NNH) of 881 reported by the authors in a high-risk population is highly sensitive to the incidence of GIB in the population. For example, if we assume a 30% baseline risk of bleeding recurrence in a year in patients with frequent episodes of GIB, the NNH would decrease to 5. Hence, the seemingly trivial NNH of 881 becomes much more relevant in the subgroup with the highest bleeding: a case-control study . J Clin Psychopharmacol 2009 ; 29 : 33 -8 . 5. Hackam DG , Mrkobrada M . Selective serotonin reuptake inhibitors and brain hemorrhage: a meta-analysis . Neurology 2012 ; 79 : 1862 -5 . 6. de Abajo FJ , Garcia-Rodriguez LA . Risk of upper gastrointestinal tract bleeding associated with selective serotonin reuptake inhibitors and venlafaxine therapy: interaction with nonsteroidal anti-infl ammatory drugs and eff ect of acid-suppressing agents . Arch Gen Psychiatry 2008 ; 65 : 795 -803 . 7. Hippisley-Cox J , Coupland C . Predicting risk of upper gastrointestinal bleed and intracranial bleed with anticoagulants: cohort study to derive and validate the QBleed scores . BMJ 2014 ; 349 : g4606 .