SSRI’s and epistaxis?

[ryerica22]

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Hi All, I have 17 yo make in My outpatient clinic with Anxiety who has shown some benefit with Fluoxetine 20mg. He had been on it for a month but stopped due to nose bleeding (happened only once) he attributes it to fluoxetine. I have explained to them that the risk is very minimal his mom is very concerned. I was wanting to perhaps switch agents but his nosebleeds could be due to lack of humidity or other factors. No other medical issues and CBC and coag studies were normal. What do you guys advise?

 

[abcxyz0123]

ssris do carry some theoretical risk of increased bleeding; we have serotonin receptors on our platelets.

while other factors may have exacerbated the bleeding in context of pt taking prozac, better to listen to pt and moms concerns and switch, otherwise they will feel like you are not validating their concerns/hearing them out. zoloft has higher evidence base for anxiety disorders in adolescents anyway.

 

[Jules A]

So unlikely this isolated incident was caused by the Prozac and stopping it isn't going to immediately clear it from his system. It depends on the details and Mom's anxiety level also but I'd discuss thoroughly, including the agnst component severe anxiety can bring when trialing a new medication, and attempt to encourage them to consider restarting in an effort to bring about some growth with regard to avoidance tolerance. Hopefully he has a decent therapist also.

 

[NickNaylor]

Agree with the above. Theoretically possible as SSRIs (and fluoxetine in particular) interfere with platelet functioning, but if this effect was so pronounced as to actually be clinically relevant, I would have expected recurrent bleeding, not a single episode.

I've found in my patients with primary anxiety disorders, it can be quite difficult to get them on a medication that they are agreeable to taking regularly for exactly this reason. They seem to become quite preoccupied with side effects. I think I read somewhere that there is some evidence supporting the idea that patients with anxiety disorders are more likely to experience side effects from medical interventions compared to those without.

If this were my patient, I'd probably switch to a different medication because, after all, you have plenty of options. In my patients where this becomes a significant problem, though - i.e., we've tried numerous agents and all have been intolerable due to one side effect or another - I eventually have a candid discussion with them about this phenomenon.

 

[whopper]

Everything is a spectrum. You will have some people who are outliers who have reactions not to be expected. Some very realistic explanations...1) He could be on other things that increase his bleeding and Fluxoetine was the tipping point such as Ibuprofen or Fish Oil. 2) He could be a slow metabolizer of the medication so even a small dose could have equivalent effects of a much bigger dosage 3) he could be abusing substances and is using the Fluoxetine as a cover-up. 4) He could have a coagulation disorder not detected until now or something on the subthreshold of one and the Fluoxetine made it apparent.


Bear in mind that even in a bell curve 3 standard deviations away is about 99.9%. So to get that 1 out of 1000 patient you need to see 1000. How many do you see in a day? I see about 15. So that's about every 3-4 months where I'll get a reaction out of a patient that's on the order of 1 in 1000.

That's about 3-4x a year I'll see a very weird reaction simply based on equation alone.

As my Fellowship PD said, if nothing abnormal is happening in your life experience that's not normal. You don't flip a coin 100x and expect it to go heads then tails then heads then tails. You're going to have a few streaks of a few heads and tails in a row.