The impact of selective serotonin receptor inhibitors on post-endoscopic sphincterotomy bleeding, alone or with concurrent aspirin or nonsteroidal anti-inflammatory drugs

Abstract

Background:Observational studies have shown an increased risk of upper gastrointestinal bleeding in users of selective serotonin receptor inhibitors (SSRIs). We retrospectively investigated the impact of SSRIs, alone or combined with aspirin (ASA) or nonsteroidal anti-inflammatory drugs (NSAIDs), on the incidence of post-endoscopic sphincterotomy (post-ES) bleeding.Methods:A total of 3058 patients were included. Of these, 457 patients received SSRIs, alone or plus ASA or NSAIDs, until the day of ES (SSRIs group), while 2659 patients (non SSRIs group) had never been on SSRIs (n=1925), though some had been on ASA (n=613) or NSAIDS (n=121). Patient assessment included indication for endoscopic retrograde cholangiopancreatography (ERCP), comorbid diseases, detailed drug history before and after ES, procedural details, and risk factors for post-ES bleeding. Primary outcome was defined as the incidence, type and severity of post-ES bleeding.Results:There was no statistical difference in age, sex, indication for ERCP, comorbid diseases, technical characteristics or results of therapeutic ERCP between the 2 groups. The incidence of post-ES bleeding was 3.9% in the SSRIs group and 3% in the non SSRIs group, a difference not statistically significant (P=0.754). Likewise, there was no difference in type (P=0.145) or severity of bleeding (P=0.754) between the 2 groups. Multivariate analysis showed the precut technique as the only independent risk factor for post ES hemorrhage (odds ratio 2.56, 95% confidence interval 1.23-3.63; P=0.001).Conclusion:This study found that SSRIs, alone or combined with ASA or NSAIDs, had no influence on the incidence or the severity of post-ES bleeding.

Bleeding in patients on concurrent treatment with a selective serotonin reuptake inhibitor (SSRI) and low‐dose acetylsalicylic acid (ASA) compared with SSRI or low‐dose ASA alone—A systematic review and meta‐analysis

“…After removal of duplicates, the literature search identified 1062 unique publications, 23 of which were included in this systematic review 16,18,26–46 . One additional study was identified through a recent systematic review 47 (Figure 1).…”

“…In all, one RCT, 39 14 cohort studies, 16,18,29,31,34,35,37,38,[40][41][42][43]45,46 and nine case-control studies [26][27][28]30,32,33,36,44,47 met the PICO criteria of this review (Table 1). Four studies utilized data from more than one country.…”

“…39,40,43,44 The remaining studies were based on data from one country (Canada, 18,42 China, 31,45 Denmark, 16,26,27,37,47 Finland, 34 Greece, 35 Iceland, 32,33 Italy, 29 Taiwan, 38,46 the United Kingdom 28,30 and the United States 36,41 ). Seventeen studies were assessed to have major risk of bias 16,[26][27][28][32][33][34][35][36][40][41][42][43][44][45][46][47] (Table 2); the seven remaining studies formed the basis for our conclusions. 18,[29][30][31][37][38][39] Reasons underlying the directness, risk of bias and precision assessments are described in Table…”

“…Eighteen nonrandomized studies provided results regarding I (SSRI + ASA) and C1 (ASA), 18,26,[29][30][31][32][33][34][35][36][37][38]40,41,43,[45][46][47] (Table 1), nine of which reported the results as a comparison between these groups. 18,30,31,[36][37][38]40,41,45 Five nonrandomized studies were assessed not to have major risk of bias (Table 2).…”

“…One RCT 39 and 13 nonrandomized studies 16,[26][27][28][29][32][33][34][35]42,44,46,47 provided results regarding I (SSRI + ASA) and C2 (SSRI), three of the latter clearly reporting the results of a comparison between these groups. 27,29,39 The RCT including 1048 patients 39 and one propensity score-(PS) matched nonrandomized study including 18 920 patients for this comparison 29 were assessed not to have major risk of bias (Table 2).…”