SSRI/SNRI Therapy is Associated With a Higher Risk of Gastrointestinal Bleeding in LVAD Patients

Mawardi, George; Markman, T.; Muslem, Rahatullah; Sobhanian, M.; Converse, M.; Meadows, Holly B.; Uber, Walter E.; Russell, Stuart D.; Rouf, Rosanne; Ramu, Bhavadharini; Judge, Daniel P.; Tedford, Ryan J.; Houston, Brian A.

doi:10.1016/j.hlc.2019.07.011

Cited by 15 publications

(8 citation statements)

References 38 publications

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“…Thus, a direct comparison of results within the GIB category is not possible. However, our findings of an association with SRI intake and higher bleeding rates are in line with results of a recent multi-institutional retrospective study of Mawardi et al of 248 LVAD patients, who reported an independent association of SSRI/SNRI therapy (including mirtazapine as mixed substance) with higher rates of GIB (OR 1.78, p = 0.045) [ 13 ] and a previous retrospective cohort study by Schultz et al, who also found a higher risk of GIB on serotonergic antidepressant therapy in their sample of 64 LVAD patients [ 14 ]. Different to our protocol, Mawardi et al investigated solely post-discharge bleedings of patients with LVAD support of at least 100 continuous days [ 13 ].…”

Section: Discussionsupporting

confidence: 92%

“…However, our findings of an association with SRI intake and higher bleeding rates are in line with results of a recent multi-institutional retrospective study of Mawardi et al of 248 LVAD patients, who reported an independent association of SSRI/SNRI therapy (including mirtazapine as mixed substance) with higher rates of GIB (OR 1.78, p = 0.045) [ 13 ] and a previous retrospective cohort study by Schultz et al, who also found a higher risk of GIB on serotonergic antidepressant therapy in their sample of 64 LVAD patients [ 14 ]. Different to our protocol, Mawardi et al investigated solely post-discharge bleedings of patients with LVAD support of at least 100 continuous days [ 13 ]. Since in our sample a bleeding event occurred in median after 65 days, limiting the included patients to those with at least 100 continuous days of LVAD implantation, bleeding events in the early stage after implantation in patients with short-term VAD support would not have been considered.…”

Section: Discussionsupporting

confidence: 92%

“…Since they, did not further differentiate between individual classes of antidepressants in a bleeding event, comparability to our results is limited. As most of the prior evidence in VAD patients, Mawardi et al [ 13 ] and Schultz et al [ 14 ] limited their research to LVAD patients. Our sample, however, also comprised BiVAD patients.…”

Section: Discussionmentioning

confidence: 99%

“…In cardiac surgery, to date, SRI use and risk of bleeding has mainly been investigated in coronary artery bypass grafting (CABG) patients, who did not show an elevated bleeding risk under SRI medication [ 12 ]. Evidence on bleeding risk and SRI intake in VAD patients is hitherto scarce and limited to reports on an increased risk of gastrointestinal bleeding (GIB) in left ventricular assist device (LVAD) patients under SRI [ 13 ] and serotonergic antidepressants [ 14 ], respectively.…”

Section: Introductionmentioning

confidence: 99%

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The use of serotonin reuptake inhibitors increases the risk of bleeding in patients with assist devices

Auschra

Wilhelm

Husung

et al. 2022

BMC Cardiovasc Disord

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Background Bleedings are frequent and dreaded complications in heart failure patients with ventricular assist devices (VAD). Serotonin reuptake inhibitor (SRI) antidepressants are widely used to treat depression in these patients, though they are attributed an increased risk of bleeding due to their modification of hemostasis. Evidence on bleeding risk of VAD patients under SRI medication is scarce and limited. We therefore aimed to assess if SRI use is associated with an elevated bleeding risk in this particularly vulnerable population. Methods We analyzed the medical records of 92 VAD patients at the University Heart Center Zurich between September 2004 and April 2018 for the occurrence of bleedings and the concomitant use of an SRI. Bleeding was defined as any type of post-implantation bleeding requiring medical treatment. We performed univariate analyses and linear mixed-effects models, adjusting for baseline clinical characteristics as potential predictors to identify differences in bleeding rates in patients with vs. without SRI intake. Results The cohort comprised 60.9% of patients with a continuous-flow VAD and 39.1% with a pulsatile-flow VAD. A total of 77.2% of patients experienced at least one bleeding incident. Overall, 28.6% of bleedings occurred under SRI therapy. A generalized linear mixed model showed a predictive effect of SRI medication on bleeding rate, independent of VAD type (z = 2.091, p = 0.037). Conclusions Bleeding events in heart failure patients occur frequently after VAD implantation. Patients with SRI medication were at increased risk of bleeding. The indication and use of SRI, therefore, should be considered carefully.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

The use of serotonin reuptake inhibitors increases the risk of bleeding in patients with assist devices

Auschra

Wilhelm

Husung

et al. 2022

BMC Cardiovasc Disord

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“…The group concluded that holding SNRI/SSRIs prior to cardiac surgery is unnecessary as it relates to the risk of perioperative bleeding [63]. In contrast, Mawardi et al found that SNRI use independently increases risk of gastrointestinal bleeding in LVAD patients [65]. Recent research also suggests that SSRIs/SNRIs may be associated with poor postoperative outcomes following hepatic resection, and should be held in the perioperative period [66].…”

Section: Intraoperative Considerationsmentioning

confidence: 99%

New Serotonin-Norepinephrine Reuptake Inhibitors and Their Anesthetic and Analgesic Considerations

Fanelli

Weller

Liu

2021

Neurology International

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Serotonin-norepinephrine reuptake inhibitors (SNRIs) inhibit the presynaptic neuronal uptake of serotonin and norepinephrine and prolong the effects of the monoamines in the synaptic cleft within the central nervous system, leading to increased postsynaptic receptor activation and neuronal activities. Serotonin-norepinephrine reuptake inhibitors can have multiple clinical indications, including as the first-line agents for the management of depression and anxiety, and as analgesics in the treatment of chronic pain. The effects of reuptake inhibition of norepinephrine and serotonin are often dose-dependent and agent-dependent. There are five FDA-approved serotonin-norepinephrine reuptake inhibitors (desvenlafaxine, duloxetine, levomilnacipran, milnacipran and sibutramine) currently being marketed in the United States. As the COVID-19 pandemic significantly increased the incidence and prevalence of anxiety and depression across the country, there are significantly increased prescriptions of these medications perioperatively. Thus, anesthesiologists are more likely than ever to have patients administered with these agents and scheduled for elective or emergency surgical procedures. A thorough understanding of these commonly prescribed serotonin-norepinephrine reuptake inhibitors and their interactions with commonly utilized anesthetic agents is paramount. There are two potentially increased risks related to the continuation of SNRIs through the perioperative period: intraoperative bleeding and serotonin syndrome. SNRIs have some off-label uses, more new indications, and ever-increasing new applications in perioperative practice. This article aims to review the commonly prescribed serotonin-norepinephrine reuptake inhibitors and the current clinical evidence regarding their considerations in perioperative anesthesia and analgesia.

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Association of bleeding with serotonergic antidepressants in patients receiving left ventricular assist device support

et al. 2021

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SSRI/SNRI Therapy is Associated With a Higher Risk of Gastrointestinal Bleeding in LVAD Patients

Cited by 15 publications

References 38 publications

The use of serotonin reuptake inhibitors increases the risk of bleeding in patients with assist devices

The use of serotonin reuptake inhibitors increases the risk of bleeding in patients with assist devices

New Serotonin-Norepinephrine Reuptake Inhibitors and Their Anesthetic and Analgesic Considerations

Association of bleeding with serotonergic antidepressants in patients receiving left ventricular assist device support

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