Thromb Haemost 2023; 123(01): 054-063
DOI: 10.1055/a-1932-8976
Cellular Haemostasis and Platelets

Concomitant Use of Selective Serotonin Reuptake Inhibitors and Oral Anticoagulants and Risk of Major Bleeding: A Systematic Review and Meta-analysis

Alvi A. Rahman
1   Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
2   Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
,
Na He
1   Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
2   Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
3   Department of Pharmacy, Peking University Third Hospital, Beijing, People's Republic of China
,
Soham Rej
2   Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
4   Department of Psychiatry, McGill University, Montreal, Canada
,
Robert W. Platt
1   Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
2   Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
5   Department of Pediatrics, McGill University, Montreal, Canada
,
1   Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
2   Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
6   Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
› Author Affiliations
Funding There was no funding for this study.


Abstract

Background Selective serotonin reuptake inhibitors (SSRIs), the most prescribed antidepressants, are associated with a modestly increased risk of major bleeding. However, in patients treated with both SSRIs and oral anticoagulants (OACs), the risk of major bleeding may be substantial.

Objective To assess the risk of major bleeding associated with concomitant use of SSRIs and OACs, compared with OAC use alone.

Methods We searched MEDLINE, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials (from inception to December 1, 2021) for clinical trials and observational studies assessing the association between concomitant use of SSRIs and OACs and the risk of major bleeding. Given sufficient homogeneity of studies, we conducted a random-effects meta-analysis to estimate a pooled hazard ratio (HR) of major bleeding associated with concomitant use of SSRIs and OACs, compared with OAC use alone.

Results The review comprised 14 studies, including 7 cohort and 7 nested case–control studies. Following assessment of clinical and methodological heterogeneity, eight studies with a total of 98,070 patients were eligible for the meta-analysis. The pooled HR of major bleeding associated with concomitant use of SSRIs and OACs was 1.35 (95% confidence interval [CI]: 1.14–1.58). In secondary analyses, the pooled HR for concomitant use of SSRIs and direct OACs was 1.47 (95% CI: 1.03–2.10).

Conclusion Concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding. Overall, our findings suggest that physicians may need to tailor treatment according to individual patient risk factors for bleeding when prescribing SSRIs to patients using OACs.

Author Contributions

A.A.R. and C.R. conceived the study. A.A.R., C.R., and R.W.P. developed the design and methodology of the study. A.A.R., N.H., and C.R. were involved in the acquisition, analysis, or interpretation of data. A.A.R. and C.R. drafted the manuscript, and all authors critically revised the manuscript.


Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.


Supplementary Material



Publication History

Received: 13 May 2022

Accepted: 23 August 2022

Accepted Manuscript online:
29 August 2022

Article published online:
28 October 2022

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