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Could SSRIs be used as antiplatelet drugs?
- ALOK KUMAR SINGH, Rameswar nath chaurashia, Rohit Tiwari (14 September 2005)
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SSRI vs Tricyclics
- Shah M Tauzeeh, London N12 OJE (15 September 2005)
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A sufficient reason to avoid SSRIs
- James Penston (15 September 2005)
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SSRI and abnormal bleeding : Possible mechanisms
- Prasanta Padhan (16 September 2005)
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Mechanism of GI Bleed with SSRIs
- Rajeev Krishnadas (26 September 2005)
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Antidepressant Options and Risk for GI Bleeding
- John D. Wynn (6 December 2006)
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ALOK KUMAR SINGH, Senior Resident Deptt of Cardiology IMS BHU VARANASI-221005, Rameswar nath chaurashia, Rohit Tiwari
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Sir I read the above editorial, which is very convincing that uppergastrointestinal bleeding is increased with selective serotonin reuptake inhibitors {SSRIs} and it is also clear from the described reason, that increased bleeding is due to antiplatelet effect. After reading this editorial, I wondered whether this class of drugs could be used as antiplatelet drugs for the prevention of coronary artery disease. I am not aware of the use of SSRIs as antiplatelet drugs. Could they not be the choice of antiplatelet in patients with coronary artey disease who suffer from depression, instead of combing with aspirin, which may potentiate the bleeding complication of each other. Although this concept seems logical, in the era of evidence medicine further studies are needed to substantiate this. Dr ALOK KUMAR SINGH
Competing interests: No |
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Shah M Tauzeeh, Associate Specialist Finchley Memorial Hospital Granville Road, London N12 OJE
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Thanks for the editorial discussing the way SSRI's are associated with gastro-intestinal bleeding. Since the early days of SSRI,the Britsh National Formulary has been mentioning gastro- intestinal bleeding under the sub-heading of 'caution'for these group of drugs. The sales representatives always appeared to be quiet when this particular issue was raised for clarification and requests for furher information was either forgotten or deliberately ignored. Without the advantage of available supporting evidence,the editorial advocates gastro-protection for patients receiving SSRI, NSAID and aspirin in both younger and elderly age group. The editorial acknowledges that the gastroprotective agents have not been shown to reduce the risk of gastro- intestinal bleeding and furher studies are needed to evaluate the recommended combination of medications. In this context is it worth considering tricyclic antidepressants instead of SSRI for patients with depression and high risk of gastro- intestinal bleeding? shah.tauzeeh@barnet-pct.nhs.uk Competing interests: None declared |
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James Penston, Consultant Physician/Gastroenterologist Scunthorpe General Hospital, Cliff Gardens, Scunthorpe, North Linconshire DN15 7BH
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Sir, Paton and Ferrier [1] draw attention to the increased risk of upper gastrointestinal haemorrhage in patients treated with selective serotonin reuptake inhibitors. The evidence which they present supports a causal link between these drugs and bleeding from the gastrointestinal tract. This is clearly of concern, especially as the use of SSRIs is so widespread. The authors propose that certain subgroups of patients – for example, those with a history of gastrointestinal haemorrhage or those taking ulcerogenic drugs – should be given proton pump inhibitors if prescribed SSRIs. However, what is missing from their discussion is any mention of avoiding the use of SSRIs. Consider, for instance, the current guidelines encouraging the early use of anti-depressants in patients with cerebrovascular accidents. [2] Almost inevitably, these patients will already be receiving aspirin and the majority will be elderly. Such patients would be at substantial risk of gastrointestinal haemorrhage if given SSRIs and, should they develop bleeding, the mortality would be significant. Similar arguments apply to the use of SSRIs in patients with depression following myocardial infarction. The question is, of course, whether anti-depressants really make a large enough difference to justify exposing patients to potentially serious side effects. In the case of elderly patients with co-existent disease and who are receiving NSAIDS or aspirin, the minor benefits of SSRIs are surely insufficient to warrant exposure to the dangers of such treatment. [1] Paton C & Ferrier IN. SSRIs and gastrointestinal bleeding. BMJ 2005;331;529-30. [2] National clinical guidelines for stroke (2nd Edition). Intercollegiate Stroke Working Party. The Royal College of Physicians, 2004. Competing interests: None declared |
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Prasanta Padhan, MD,SENIOR RESIDENT IN INTERNAL MEDICINE JIPMER,PONDICHERRY,INDIA.605006
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Dear Editor, Apart from gastrointestinal bleeding,SSRIs also increase the risk of uterine bleeding,brain hemorrhages,abnormal bleeding in joints,nose bleeds,and bleeding within the bladder.This may result due to following mechanisms.Platelet factor-4 and beta-thromboglobulin are two thrombogenic proteins released into the blood when platelets are activated.Serotonin potentiates platelet activation.SSRIs decrease serotonin uptake from blood to platelets.Since platelets do not synthesize serotonin, SSRIs are associated with increases in bleeding episodes. Competing interests: None declared |
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Rajeev Krishnadas, Senior House Officer in Psychiatry South tyneside District Hospital, South Shields, NE34 0PL
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Sir, I read with interest the article by Carol Paton and Prof Ferrier, on SSRI and GI bleed (1) . The authors note that there is an association between SSRI and GI bleed. On reading the article, few queries did pop into my mind. 1. The authors state that the mechanism of action by which SSRIs and NSAIDs cause GI bleed differ. SSRIs acting centrally on the platelets and NSAIDs acting peripherally on the mucosa. My query is, Serotonin being present through out the gut, could the SSRIs have local action on the mucosa as well? If not, how can SSRIs cause bleeding if the mucosa/ vessel wall is intact? And why specifically GI bleed? 2. The authors note that studies have shown an association between transporter affinity and GI bleed. One of the studies they quote (2), show that the risk of bleed was most with Trazodone. Trazodone having weak effect on the serotonin reuptake mechanism. This may mean that the action of the various drugs may not be restricted to the reuptake mechanism, but may be multifactorial. 3. The authors very rightly point out that Gastroprotective agents may not be useful for patients only on SSRIs. This may be because SSRIs induce nausea and vomting, through their action on the 5HT3 receptors at the Chemoreceptor trigger zone, which may lead to secondary gastritis, thus increasing the risk for a bleed. [1]Paton C & Ferrier IN. SSRIs and gastrointestinal bleeding. BMJ 2005;331;529-30 [2]De Abajo FJ, Rodriguez AG, Montero D. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding. BMJ 1999;319: 1106-9. Competing interests: None declared |
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John D. Wynn, Medical Director PsychoOncology; Clinical Associate Professor Swedish Cancer Institute; U. Washington School of Medicine; Seattle, WA 98104
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It is worth noting that the antihistaminic (and perhaps the anticholinergic) activity of tricyclic antidepressants (imipramine, nortriptyline, clomipramine and others) may provide further prophylaxis against gastric bleeding in patients thus treated for depression and anxiety states. See, for example: Ries RK, Gilbert DA, Katon W(1984):Tricyclic antidepressant therapy for peptic ulcer disease. Arch Int Med 144(3):566-569 Competing interests: None declared |
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