SSRI/SNRI + Coumadin? Your Thoughts

[Blitz2006]

Are you ok with prescribing SSRI/SNRI with a patient that is on coumadin?

As we all know, on one hand, it can increase INR/PT, although it appears quite low, as per these review articles:

Warfarin and Antidepressants: Happiness without Hemorrhaging

Warfarin, a commonly prescribed anticoagulant, has a very narrow therapeutic index. Because a multitude of drugs may potentially alter warfarin levels, primarily through the cytochrome P-450 isoenzyme system, in this edition of The Interface, we explore ...

www.ncbi.nlm.nih.gov

https://www.ahajournals.org/doi/10.1161/JAHA.118.008755

Although this study suggests there is an increase in risk of hemorrhage:

Effect of Selective Serotonin Reuptake Inhibitors on Bleeding Risk in Patients with Atrial Fibrillation Taking Warfarin

Selective serotonin reuptake inhibitor (SSRI) medications have been linked to increased bleeding risk, however, the actual association between warfarin, SSRI exposure, and bleeding risk has not been well-established. We studied the AnTicoagulation and ...

www.ncbi.nlm.nih.gov

On the other hand, these patients are usually closely monitored in anti-coagulation clinics, monitoring INR, so I presume it should be ok?

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[nowaysanjose]

IIRC Luvox and Prozac are the worst as they are hitting cyp stuff hardest. Had a few cases with Lexapro that were fine. Maybe others could weigh in more

 

[splik]

it depends on the SSRI. My go to is usually sertraline for these patient followed by escitalopram. venlafaxine is another option.
There are two issues. One is pharmacokinetics which mean avoiding certain meds that will increase warfarin levels. The second is pharmacodynamics in this case the modest effects of SSRIs on platelet aggregation increasing bleeding risk. this risk is modest but real, and not something that can be monitored in an anticoagulant clinic or by monitoring INR (since that is not the issue).

 

[robellis]

it depends on the SSRI. My go to is usually sertraline for these patient followed by escitalopram. venlafaxine is another option.
There are two issues. One is pharmacokinetics which mean avoiding certain meds that will increase warfarin levels. The second is pharmacodynamics in this case the modest effects of SSRIs on platelet aggregation increasing bleeding risk. this risk is modest but real, and not something that can be monitored in an anticoagulant clinic or by monitoring INR (since that is not the issue).

The kinetic issue really isn’t an issue though because you’re measuring inr and can adjust the dose right?

 

[hebel]

Ignoring pharmacokinetics, maudsley says the warfarin/ssri combo has an absolute risk of UGIB of 4%, compared to nsaid/ssri of 3% and aspirin/ssri of 6%.

 

[Sushirolls]

Go low, go slow, make sure they are following up as expected at the coumadin clinic.