SSRIs and GI bleeding

[rhiannon777]

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What would you recommend for treating a patient who had a GI bleed on an SSRI? There's plenty of information out there about the risk, mechanisms, etc. of the bleed, but I haven't been able find anything on treatment or follow up. I was thinking Wellbutrin might be a good alternative medication, but "GI hemorrhage" is listed in the giant list of possible side effects. Thoughts?

 

[nitemagi]

Went through micromedex and epocrates, and I see no listing of GI bleed as a risk with bupropion. I'd double check your source. Could be a class listing for all antidepressants, rather than a legitimate side effect of WBT. And even if it is true, the mechanism would be different so could be worth a trial.

 

[heyjack70]

Seroquel XR!

 

[billypilgrim37]

Emsam.

 

[strangeglove]

There's a study somewhere showing that platelet dysfunction is correlated with the amount of serotonin reuptake inhibition. Thus, Remeron would also be a good choice, I think. No issue with Wellbutrin.

 

[rhiannon777]

Went through micromedex and epocrates, and I see no listing of GI bleed as a risk with bupropion. I'd double check your source. Could be a class listing for all antidepressants, rather than a legitimate side effect of WBT. And even if it is true, the mechanism would be different so could be worth a trial.

It came from Up to Date, but my impression was that it was a big block of those things that happened to one or two people during the drug research, so no one knows whether they have any actual relationship to the drug.

 

[nitemagi]

It came from Up to Date, but my impression was that it was a big block of those things that happened to one or two people during the drug research, so no one knows whether they have any actual relationship to the drug.

Per the GSK site there's a risk when co-administered with Warfarin (duh) for change in INR, and even drop in cell lines (?). I'd go through informed consent on the risk, and if the pt. is amenable give it a try. Almost every other antidepressant has serotonergic activity (SSRI, TCA, MAOI), so it might be your best bet still.

 

[whopper]

While SSRIs can contribute to bleeding they are usually nowhere near the level of importance as other factors such as Coumadin. It's possible that if Coumadin is needed, one could put it on a lower dosage where it's still therapeutic.

I'd look at the patient's entire situation and see if other things could be done first before fiddling with SSRIs. If the SSRI she is on works, playing around with what worked is messing with success. A new antidepressant may not work.


But as mentioned there are several options. I'll throw in you could lower the SSRI and augment it with another med.

 

[nitemagi]

They should of course also have a full w/u to eliminate other causes of bleeding (PT/INR/PTT, bleeding time, factor deficiencies, vitamin K, genetic, other meds, etc).

 

[BobA]

And don't forget psychotherapy 😉

 

[nitemagi]

And don't forget psychotherapy 😉

👍

 

[michaelrack]

don't forget ECT

 

[digitlnoize]

What would you recommend for treating a patient who had a GI bleed on an SSRI? There's plenty of information out there about the risk, mechanisms, etc. of the bleed, but I haven't been able find anything on treatment or follow up. I was thinking Wellbutrin might be a good alternative medication, but "GI hemorrhage" is listed in the giant list of possible side effects. Thoughts?

Are we sure it was related? Ulcerative Colitis?

 

[BobA]

👍

don't forget ECT

 

[BobA]

Are we sure it was related? Ulcerative Colitis?

Usually this situation will show up as a consult where the GI folks will make the determination about the cause of the GI Bleed (often times it's just felt that the SSRI contributes) and then they ask psych for recs about alternatives for depression treatment.

 

[9point75]

Where I've trained and worked, we've had cardiac surgeons take people to the OR for CABG's while on SSRI's. I find the risk to more of a theorhetical one at best.

 

[DD214_DOC]

Where I've trained and worked, we've had cardiac surgeons take people to the OR for CABG's while on SSRI's. I find the risk to more of a theorhetical one at best.

This is how I feel. One of my research projects is to attempt to quantify the level of risk for SSRIs but I'm finding it really difficult to get it done in the short amount of time that residency affords.

 

[whopper]

I haven't touched the scientific data on this in the last several months, but from all accounts I've read, SSRIs usually aren't significant with bleeding. Yes they could cause bleeding, there is an increased risk, but it's nothing on the order of meds such as Coumadin.

If someone had GI bleeding and was on an SSRI, of course I'd factor it in as a possible cause of the problem, but I'd be looking at a heck of a lot of things such as all their meds, any bleeding disorders, etc.

If the SSRI works, and there's a GI bleeding problem, my initial thought would be to see if there was anything else that could be done before getting them off the SSRI. E.g. are they on ASA 325 mg Qdaily? Lower it to 81 mg Qdaily. There's data showing that ASA is not really more effective for preventing heart attacks at 325 Qdaily and it just increases the risk of bleeding. Are they taking 3 g of fish oil a day? Lower it to 1-2 g a day.
http://www.theheart.org/article/789113.do

Remember, not all antidepressants work in everyone. Sometimes you get them off of one, you try 5 others and none of the others could work. In medicine there are usualy plenty of options. If an SSRI works, don't be so quick to stop it, but of course do consider it among all the options available.