Serotonin gastrointestinal bleeding

A potentially dangerous interaction may occur between fluvoxamine and warfarin. There is a 65% increase in plasma warfarin concentration and a significant prolongation of prothrombin time. The selective serotonin reuptake inhibitors (SSRIs) increase the risk of upper gastrointestinal bleeding, and this effect is potentiated by the concurrent use of non-steroidal anti-inflammatory drugs (NSAIDs) or low-dose aspirin. There are anecdotal reports of bleeding disorder with the concomitant use of nicoumalone (a coumarin derivate), ibuprofen, and warfarin. 

Van Walraven C, Mamdani MM, Wells PS, Williams JI. Inhibition of serotonin reuptake by antidepressants and upper gastrointestinal bleeding in elderly patients retrospective cohort study. BMJ(200 ) 323,655-8. 

De Abajo FJ, Rodriguez LAG, Montero D. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding population based case-control study. BMJ (1999)319,1106-9. 

Serotonin release by platelets plays an important role in hemostasis. Psychotropic drugs that interfere with serotonin reuptake may increase the occurrence of upper gastrointestinal bleeding with concurrent use of an NSAID or aspirin. Altered anticoagulant effects have been reported when either SSRIs or SNRIs are co-administered with warfarin. Hemostasis in warfarin therapy should be carefully monitored whenever duloxetine is initiated or discontinued. 

Targownik LE, Bolton JM, Metge CJ, Leung S, Sareen J. Selective serotonin reuptake inhibitors are associated with a modest increase in the risk of upper gastrointestinal bleeding. Am J Gastroenterol 2009 104(6) 1475-82. 

Dalton SO, Johansen C, Mellemkjaer L, et al Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding a population-based cohort study. Arch Intern Med 163 59-64, 2003... 

St. John s wort Mild to moderate depression Gastrointestinal upset, photo-sensitivity. Mild serotonin syndrome with the following medications paroxetine, trazodone, sertraline, and nefazodone. May decrease digoxin levels. May decrease cyclosporine serum concentrations. Combined oral contraceptives—breakthrough bleeding. 

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