Bleeding risk reduced in depressed patients with pain

ACID-SUPPRESSING medications may significantly reduce the risk of upper gastrointestinal (GI) tract bleeds resulting from concurrent use of SSRIs and NSAIDs, an Australian expert says.

A study of 1321 UK patients referred to a hospital or consultant for upper GI bleeds, found that when matched to 10,000 control subjects, those taking both an SSRI and an NSAID had a nine times greater risk of bleeding if they were not also using an acid suppressant.

However, if they were using an acid suppressant as well, the risk of bleeding was reduced to only 1.3 times more than controls.

Professor Terry Bolin, Sydney gastroenterologist and president of The Gut Foundation, said the findings suggested GPs should prescribe proton pump inhibitors (PPIs) to high-risk patients taking a combination of SSRIs and NSAIDs.

“I would advocate PPIs in people who are of high risk – people over the age of 60, with a past history of an ulcer and who are also co-prescribed aspirin or clopidogrel and with current indigestion.”

He said the presence of Helicobacter pylori increased the risk of GI bleeds by six times and H. pylori status should be checked as a first-line management strategy for patients in whom SSRI and NSAID use was being considered.

The authors estimated it would take 2000 patients per year treated with SSRIs for one case of upper GI bleeding to occur, however the number needed to treat would “decrease remarkably” in those also using NSAIDs.

“These data indicate that in such a high-risk population, the use of acid-suppressing agents would save a relevant number of cases and is worthwhile.”

Arch Gen Psychiatry 2008; 65:795-803.