Risks of hospitalization for upper gastrointestinal bleeding in users of selective serotonin reuptake inhibitors after Helicobacter pylori eradication therapy: a propensity score matching analysis

Abstract

Summary Background Selective serotonin reuptake inhibitors (SSRIs) are the first‐line treatment for depression but there is a concern about the risk of upper gastrointestinal bleeding (UGIB). Past studies, however, are largely confounded by the presence of Helicobacter pylori (HP). Aim To evaluate the UGIB risk of SSRI users after treatment for HP. Methods This was a propensity score (PS) matched cohort study with patients who used SSRI after receiving HP eradication therapy from the Hong Kong territory‐wide healthcare database. The primary outcome was hospitalisation for nonvariceal UGIB. PS matching analysis with a ratio of 1:2 plus Cox regression model was used to compute the hazards ratios (HR) and 95% CI of UGIB risk. Results In this study, 3358 SSRI users and 57 906 non‐users were included. The median follow‐up duration was 7.74 (interquartile range 5.32‐10.42) years. The crude incidence of hospitalisation for UGIB was 3.98 (95% CI 3.80‐4.16) per 1000 person‐years. In the PS matching analysis of 3358 SSRI users with 6716 non‐users, SSRI was associated with a higher risk of UGIB compared to non‐users (HR 1.95, 95% CI 1.41‐2.70). This result was consistent in sensitivity analysis with 1:1 PS matching (HR 2.13, 95% CI 1.50‐3.02) and multivariable analysis with 1‐month intervals (HR 1.81, 95% CI 1.34‐2.45) or 3‐month intervals (HR 1.61, 95% CI 1.20‐2.17). After stratifying by age, the increased risk of SSRI was only significant among patients >50 years. Conclusion SSRI users have a higher risk of hospitalisation for nonvariceal UGIB after treatment for HP, particularly among older patients.

Divergent trends of hospitalizations for upper and lower gastrointestinal bleeding based on population prescriptions of aspirin, proton pump inhibitors and Helicobacter pylori eradication therapy

“…Patient's key information, including demographics, hospitalization, visits to outpatient clinics and emergency departments, diagnoses, and drug prescription in all public hospitals and clinics are recorded. This database has been previously used in a number of high‐quality studies 12–15 . The International Classification of Diseases, 9th Revision (ICD‐9) is the coding system used in CDARS, which has been verified in our previous study on GIB 16 .…”

Who Needs Gastroprotection in 2020?

“…These results could be due to bias or residual confounding as they relate to observational data, but these findings are supported by a Hong Kong study that attempted to reduce this concern [53]. This study evaluated 3358 SSRI users and 57,906 non-users and only included patients that had H. pylori eradication therapy.…”

“…This approach makes the population more homogeneous, and they further reduced the possibility of confounding by conducting a propensity match analysis. The propensity-matched analysis found patients taking SSRI had a hazard ratio of 1.95 (95% CI = 1.41 to 2.71) for developing upper GI bleed compared to non-users [53].…”

Delay in Retreatment of Helicobacter pylori Infection Increases Risk of Upper Gastrointestinal Bleeding

“…This was a retrospective territory-wide cohort study including all H. pylori-infected patients, aged 18 or above, who had received their first course of clarithromycin-containing triple therapy between Jan 2003 and Dec 2012. [11][12][13][14] There is no restriction on indications for treatment and the usual practice is to eradicate all patients who are found to be H pylori positive due to a relatively high local incidence of gastric cancer and peptic ulcer. Clarithromycin-containing triple therapy was identified by the coprescription of clarithromycin with one proton pump inhibitors (PPI) and either amoxicillin or metronidazole with the same start date of prescriptions and overlapping duration of 7-14 days.…”