Concomitant Use of NSAIDs or SSRIs with NOACs Requires Monitoring for Bleeding

Lee, Min-Taek; Park, Kwang‐Yeol; Kim, Myo-Song; You, Seung-Hun; Kang, Ye Jin; Jung, Sun Young

doi:10.3349/ymj.2020.61.9.741

Cited by 27 publications

(44 citation statements)

References 34 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…For secondary outcomes, the use of SRI among individuals treated with anticoagulant therapy revealed a higher risk of intracranial haemorrhage (10 studies [ 24 , 29 , 30 , 33–35 , 39–42 ]; n = 443,904; OR, 1.31; 95% CI, 1.02–1.68; p = .031; Figure 3(A) ), gastrointestinal bleeding (10 studies [ 24 , 29 , 33 , 34 , 36 , 43–47 ]; n = 1085014; OR, 1.34; 95% CI, 1.19–1.50; p < .001; Figure 4(A) ), and any bleeding events (23 studies [ 24–36 , 39–48 ]; n = 1,209,421; OR, 1.39; 95% CI, 1.24–1.55; p < .001; Figure 5(A) ). Likewise, use of SRI among individuals treated with antiplatelet agents also illustrated an increased risk of gastrointestinal bleeding (five studies [ 37 , 44 , 49–51 ]; n = 52571; OR, 1.30; 95% CI, 1.04–1.63; p = .021; Figure 4(B) ), any bleeding events (11 studies [ 37–40 , 42 , 44 , 49–53 ]; n = 153,790; OR, 1.15 (95% CI, 1.06–1.25; p = .001; Figure 5(B) ), except for intracranial haemorrhage (three studies [ 39 , 40 , 42 ]; n = 81173; OR, 1.08; 95% CI, 0.93–1.26; p = .325; Figure 3(B) ).…”

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Use of serotonin reuptake inhibitor antidepressants and the risk of bleeding complications in patients on anticoagulant or antiplatelet agents: a systematic review and meta-analysis

et al. 2021

View full text Add to dashboard Cite

Background Serotonin reuptake inhibitor (SRI) antidepressants are implicated in increasing the risk of bleeding among users; however, the comparative increase in bleeding risk with concurrent antithrombotic therapy (anticoagulant or antiplatelet) remains unclear. As such, we performed a systematic review and meta-analysis of all available evidence to evaluate the effects of SRI and the risk of bleeding complications among patients receiving antithrombotic therapy. Methods We searched Medline, Embase, PubMed, PsycINFO, Cochrane Library, Web of Science, Scopus, CINAHL, and grey literature (Google Scholar and preprint reports) up to 26 November, 2020, with no language restrictions (updated on 31 July 2021). The primary outcome of interest was major bleeding. Secondary outcomes included intracranial haemorrhage, gastrointestinal bleeding, and any bleeding events. We used a random-effects model meta-analysis to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). Results We did not identify any randomised studies but found 32 non-randomized studies (cohort or case–control) with 1,848,285 patients that fulfilled the study selection criteria and were included in the meta-analysis. Among individuals receiving anticoagulants (13 studies), SRI users experienced a statistically higher risk of major bleeding compared to non-SRI users: pooled OR was 1.39 (95% CI, 1.23–1.58; p < .001; moderate heterogeneity). Among individuals receiving antiplatelet therapy (2 studies), SRI users were associated with an increased risk of major bleeding: pooled OR was 1.45 (95% CI, 1.17–1.80; p = .001; low heterogeneity). For secondary outcomes, the use of SRI among individuals treated with antithrombotic therapy revealed a higher risk of gastrointestinal bleeding or any bleeding events, whereas only anticoagulant use was illustrated an increased risk of intracranial haemorrhage. Conclusions The use of SRI antidepressants among patients treated with antithrombotic therapy (either anticoagulant or antiplatelet) is associated with a higher risk of bleeding complications, suggesting that caution is warranted in co-prescription. PROSPERO Registration CRD42018083917 KEY MESSAGES In this meta-analysis of 32 non-randomized studies, SRI users were associated with the risk of bleeding complications compared to non-SRI users, with concurrent antithrombotic use (either anticoagulant or antiplatelet). The risk was consistently elevated across types of bleeding events (major bleeding, gastrointestinal bleeding, or any bleeding events), whereas only anticoagulant use was associated with intracranial haemorrhage. To promote the rational use of medicines, our findings suggest that the risk-benefit ratio must account for the clear efficacy of SRI against safety concern...

show abstract

Section: Resultsmentioning

confidence: 99%

“…[ 41 ], Lee et al. [ 34 ], and Marchena et al. [ 35 ], there was no association between SRI use and the risk of intracranial haemorrhage among individuals receiving anticoagulant therapy.…”

Section: Resultsmentioning

confidence: 99%

Use of serotonin reuptake inhibitor antidepressants and the risk of bleeding complications in patients on anticoagulant or antiplatelet agents: a systematic review and meta-analysis

et al. 2021

View full text Add to dashboard Cite

show abstract

“…In addition, she was treated with sertraline (SSRI) for depression and this association could increase dabigatran blood concentration and so the bleeding risk. 21 Finally, in this case-report, the patient was treated with idarucizumab that reversed the hemorrage and the nephropathy evoked by dabigatran (see Table 1 and Figure 1).…”

Section: Discussionmentioning

confidence: 89%

“…Nowadays NOACs represent an opportunity to reduce thromboembolic events and, compared to warfarin, they reduce the risk of fatal bleeding, and increase compliance thanks to their fixed daily doses without any particular dietary restrictions and without International Normalized Ratio (for blood clotting time) (INR) constant monitoring. 19,20 However, we cannot forget factors that may interfere with the metabolism of NOACs, such as: kidney dysfunction (all NOACs have renal excretion, in particular, dabigatran >80%); 2 liver dysfunction, concomitant medications used to treat atrial fibrillation that could alter NOAC concentration because of interference with CYP3A4 (ie, prednisone, SSRI) 21 or P-glycoprotein (ie, verapamil and amiodarone) 2,22 ; concomitant medications used to treat atrial fibrillation that could increase the bleeding risk (ie, acetylsalicylic acid, clopidogrel, ibuprofen, diclofenac). 7,21 These are the main reasons why renal function of patients who use dabigatran should be monitored.…”

Section: Discussionmentioning

confidence: 99%

“…19,20 However, we cannot forget factors that may interfere with the metabolism of NOACs, such as: kidney dysfunction (all NOACs have renal excretion, in particular, dabigatran >80%); 2 liver dysfunction, concomitant medications used to treat atrial fibrillation that could alter NOAC concentration because of interference with CYP3A4 (ie, prednisone, SSRI) 21 or P-glycoprotein (ie, verapamil and amiodarone) 2,22 ; concomitant medications used to treat atrial fibrillation that could increase the bleeding risk (ie, acetylsalicylic acid, clopidogrel, ibuprofen, diclofenac). 7,21 These are the main reasons why renal function of patients who use dabigatran should be monitored. In fact, renal function impairment as well as interactions with other therapies could lead to a prolonged half-life of dabigatran, with a consequent increased risk of bleeding.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Dabigatran-Induced Nephropathy and Gastrointestinal Bleeding and Its Successful Treatment with Idarucizumab: A Case Report

et al. 2021

View full text Add to dashboard Cite

Recently, the atrial fibrillation treatment guidelines have been updated to now recommend Non-vitamin K antagonist oral anticoagulants (NOACs) as the preferred alternative to warfarin for systemic embolism and stroke prevention in patients with non-valvular atrial fibrillation. NOACs have major pharmacologic advantages over warfarin, although the most common complications are gastrointestinal bleeding and NOAC-induced nephropathy within 6 weeks after starting therapy, as several recent case-reports stated. We are reporting for the first time a chronic delayed adverse reaction (regularly reported to Authorities) observed in an 82-year-old woman 27 months after starting dabigatran (110 mg twice a day), characterized by concomitant gastrointestinal bleeding and nephropathy. Idarucizumab administration immediately improved both bleeding and renal parameters. Moreover, we are going to highlight the importance of the compliance, the adherence to the therapeutic plan and the supervision of the Hospital Pharmacy on drug prescriptions. In fact in our case, dabigatran was firstly prescribed by the neurologist and delivered by the hospital pharmacy, but the patient continued the treatment for 27 months, prescribed by general practitioner without any laboratory control. This lack of supervision certainly contributed to the onset of the adverse reaction reported.

show abstract

Concomitant Use of Selective Serotonin Reuptake Inhibitors With Oral Anticoagulants and Risk of Major Bleeding

Rahman,

Platt,

Beradid

et al. 2024

JAMA Netw Open

View full text Add to dashboard Cite

ImportanceSelective serotonin reuptake inhibitors (SSRIs) are commonly prescribed antidepressants associated with a small increased risk of major bleeding. However, the risk of bleeding associated with the concomitant use of SSRIs and oral anticoagulants (OACs) has not been well characterized.ObjectivesTo assess whether concomitant use of SSRIs with OACs is associated with an increased risk of major bleeding compared with OAC use alone, describe how the risk varies with duration of use, and identify key clinical characteristics modifying this risk.Design, Setting, and ParticipantsA population-based, nested case-control study was conducted among patients with atrial fibrillation initiating OACs between January 2, 1998, and March 29, 2021. Patients were from approximately 2000 general practices in the UK contributing to the Clinical Practice Research Datalink. With the use of risk-set sampling, for each case of major bleeding during follow-up, up to 30 controls were selected from risk sets defined by the case and matched on age, sex, cohort entry date, and follow-up duration.ExposuresConcomitant use of SSRIs and OACs (direct OACs and vitamin K antagonists [VKAs]) compared with OAC use alone.Main Outcomes and MeasuresThe main outcome was incidence rate ratios (IRRs) of hospitalization for bleeding or death due to bleeding.ResultsThere were 42 190 patients with major bleeding (mean [SD] age, 74.2 [9.3] years; 59.8% men) matched to 1 156 641 controls (mean [SD] age, 74.2 [9.3] years; 59.8% men). Concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding compared with OACs alone (IRR, 1.33; 95% CI, 1.24-1.42). The risk peaked during the initial months of treatment (first 30 days of use: IRR, 1.74; 95% CI, 1.37-2.22) and persisted for up to 6 months. The risk did not vary with age, sex, history of bleeding, chronic kidney disease, and potency of SSRIs. An association was present both with concomitant use of SSRIs and direct OACs compared with direct OAC use alone (IRR, 1.25; 95% CI, 1.12-1.40) and concomitant use of SSRIs and VKAs compared with VKA use alone (IRR, 1.36; 95% CI, 1.25-1.47).Conclusions and RelevanceThis study suggests that among patients with atrial fibrillation, concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding compared with OAC use alone, requiring close monitoring and management of risk factors for bleeding, particularly in the first few months of use.

show abstract

Concomitant Use of NSAIDs or SSRIs with NOACs Requires Monitoring for Bleeding

Cited by 27 publications

References 34 publications

Use of serotonin reuptake inhibitor antidepressants and the risk of bleeding complications in patients on anticoagulant or antiplatelet agents: a systematic review and meta-analysis

Use of serotonin reuptake inhibitor antidepressants and the risk of bleeding complications in patients on anticoagulant or antiplatelet agents: a systematic review and meta-analysis

Dabigatran-Induced Nephropathy and Gastrointestinal Bleeding and Its Successful Treatment with Idarucizumab: A Case Report

Concomitant Use of Selective Serotonin Reuptake Inhibitors With Oral Anticoagulants and Risk of Major Bleeding

Contact Info

Product

Resources

About