Are selective serotonin reuptake inhibitors (SSRIs) a risk factor for post-polypectomy bleeding?

We read with great interest the letter of Sarkis et al. [1] and the reply of Repici et al. [2] on post-procedure bleeding after cold polypectomy and biopsy in the gastrointestinal tract. It is interesting that in the study by Sarkis et al. one patient with post-biopsy bleeding was under treatment with paroxetine (the oldest selective serotonin reuptake inhibitor [SSRI]). Moreover, Repici et al. note that antidepressants may increase the post-procedure bleeding risk. However, there is no study that relates post-polypectomy or biopsy bleeding with use of SSRIs.

We have conducted a multicenter study to compare blended and pure coagulation current in the endoscopic mucosal resection of large sessile colorectal polyps in 109 patients (unpublished data). Among the 12 patients (11 %) who presented with post-polypectomy bleeding, two were under treatment with SSRIs and one was under treatment with SSRI plus aspirin.

SSRIs are frequently preferred to other classes of antidepressants in the treatment of depression, because of their better safety profile, particularly in older people, a group with a high rate of endoscopic interventions [4]. SSRIs block serotonin reuptake by platelets and reduce platelet serotonin, leading to impairment of the platelet hemostatic response [3]. This results in increased risk of gastrointestinal bleeding [5], an effect that is amplified by concomitant use of nonsteroidal anti-inflammatory drugs or aspirin [6]. We believe that there is need for large prospective studies that will investigate the role of SSRIs and SSRIs plus other antiplatelet drugs in hemorrhage associated with endoscopic procedures.

• References

• 1 Sarkis F, Abu Daya H, Sharara A et al. Delayed overt gastrointestinal bleeding after cold endoscopic biopsy. Endoscopy 2013; 45: 75-76
• 2 Repici A, Hassan C, Zullo A. Reply to Sarkis et al. Endoscopy 2013; 45: 77
• 3 Andrade C, Sandarsh S, Chethan KB et al. Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and reconsideration of mechanisms. J Clin Psychiatry 2010; 71: 1565-1575
• 4 Coupland C, Dhiman P, Morris R et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011; 343: d4551
• 5 Ahsberg K, Hoglund P, Kim WH et al. Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding. Scand J Gastroenterol 2010; 45: 1404-1415
• 6 Carvajal A, Ortega S, Del Olmo L et al. Selective serotonin reuptake inhibitors and gastrointestinal bleeding: a case–control study. PLoS One 2011; 6: e19819 Epub 2011 May 18