Serotonergic antidepressants increase bleeding risk in orthopedic surgery

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are the mainstay of treatment for major depression, anxiety disorders, obsessive-compulsive disorders and post-traumatic stress disorder. However, these serotonergic antidepressants block the reuptake of serotonin, causing the depletion of serotonin from platelets, which is associated with an increase in bleeding risk. Several studies have reported gastrointestinal tract bleeding and spontaneous intracranial bleeding with serotonergic antidepressants. Concerns have also been raised that use of serotonergic antidepressants during the perioperative period increases bleeding risk in patients undergoing surgical operations. To quantify the magnitude of the increased bleeding risk in patients undergoing orthopedic surgical procedures, a US study compared the rates of bleeding between orthopedic surgery patients on perioperative serotonergic antidepressants and those not on serotonergic antidepressants. The retrospective cohort study included patients who were admitted for orthopedic surgery at a 501-bed tertiary care teaching hospital. Outcomes evaluated in the study were the requirement for ≥ 2 units of packed red blood cells and length of hospital stay. Results showed the following: The study included a total of 273 patients who underwent orthopedic surgery; 171 (62.6%) patients received serotonergic antidepressants during the perioperative period. Among serotonergic antidepressant users, sertraline was the most commonly prescribed SSRI and duloxetine the most common SNRI. Of the 273 orthopedic surgery patients, a significantly higher percentage of patients who received serotonergic antidepressants required ≥ 2 units of packed red blood cells (19.3% vs 6.9%; p = 0.0049). Orthopedic surgery patients who required transfusion were older (79 vs 65 years; p < 0.0001) and more likely to have hip surgery (hip fracture repair, 37.5% vs 22.3%; p = 0.0080). The risk of requiring transfusion of ≥ 2 units of packed red blood cells was greater for individuals having an anemia comorbidity (odds ratio [OR], 4.55; 95% CI, 1.95–10.62, p = 0.0004). Patients who required ≥ 2 units of packed red blood cells had a longer median hospital stay than those who did not receive ≥ 2 units of packed red blood cells (8 vs 4 days; p < 0.0001). The researchers conclude that receiving serotonergic antidepressants in the perioperative period is associated with a higher transfusion requirement and a longer hospital stay in patients undergoing orthopedic surgery. In their retrospective study, perioperative use of serotonergic antidepressants was associated with a three-fold increase in the risk of requiring transfusion of ≥ 2 units of packed red blood cells. The authors stress that clinicians need to be aware of the increased risk in patients who are taking serotonergic antidepressants while undergoing surgical procedures. Reference: 1. Yang SH, Seifert CF. Evaluation of bleeding in orthopedic surgery with perioperative use of serotonergic antidepressants. Ann Pharmacotherapy 2023;57(8). (accessed July 13, 2023).

Serotonergic antidepressants increase bleeding risk in orthopedic surgery

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