open access
Effect of psychotropics on bleeding and clotting factors
Affiliations- Lokmanya Tilak Municipal Medical College, Mumbai, India
- Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, India
open access
Abstract
Introduction: Coagulopathies are rare side effects with psychotropics and are thus frequently overlooked while prescribing. Selective serotonin reuptake inhibitors are more commonly associated with deranged bleeding parameters, the most frequent being decreased platelet aggregability and activity, and the prolongation of bleeding time. Thrombocytopenia as a side effect of valproate administration often goes unnoticed, and olanzapine has been associated with a higher risk of venous thromboembolism.
The aim of our study was to determine what percentage of patients on psychotropics develop changes in bleeding parameters, and whether these changes are significant enough to warrant routine monitoring of these parameters.
Material and methods: This was a prospective observational, single-center study which included 100 patients newly started on psychotropics. Those on medications affecting bleeding parameters or having an acute illness like sepsis were excluded. Patients were only on a single psychotropic agent, and their bleeding parameters — prothrombin time, international normalized ratio (INR), bleeding time, clotting time (CT) and platelet count — were assessed at baseline and after 15 and 30 days.
Results: Mean values of prothrombin time (PT), INR, bleeding time and CT increased over time while the mean value of platelet count showed a decreasing trend but no clinical manifestations were noted. Olanzapine was the only drug causing a reduction of PT, INR and CT and valproate was the only drug affecting platelet count. Paroxetine affected the bleeding parameters the most among the antidepressants. Sertraline, fluoxetine, amitriptyline and haloperidol were the other drugs affecting various bleeding parameters, though the effects were less compared to the other drugs in the study.
Conclusions: Routine monitoring of bleeding parameters in patients receiving psychotropics is not warranted, but caution must be taken while prescribing these drugs, especially in groups such as patients with known blood dyscrasias or peri-operative patients.
Abstract
Introduction: Coagulopathies are rare side effects with psychotropics and are thus frequently overlooked while prescribing. Selective serotonin reuptake inhibitors are more commonly associated with deranged bleeding parameters, the most frequent being decreased platelet aggregability and activity, and the prolongation of bleeding time. Thrombocytopenia as a side effect of valproate administration often goes unnoticed, and olanzapine has been associated with a higher risk of venous thromboembolism.
The aim of our study was to determine what percentage of patients on psychotropics develop changes in bleeding parameters, and whether these changes are significant enough to warrant routine monitoring of these parameters.
Material and methods: This was a prospective observational, single-center study which included 100 patients newly started on psychotropics. Those on medications affecting bleeding parameters or having an acute illness like sepsis were excluded. Patients were only on a single psychotropic agent, and their bleeding parameters — prothrombin time, international normalized ratio (INR), bleeding time, clotting time (CT) and platelet count — were assessed at baseline and after 15 and 30 days.
Results: Mean values of prothrombin time (PT), INR, bleeding time and CT increased over time while the mean value of platelet count showed a decreasing trend but no clinical manifestations were noted. Olanzapine was the only drug causing a reduction of PT, INR and CT and valproate was the only drug affecting platelet count. Paroxetine affected the bleeding parameters the most among the antidepressants. Sertraline, fluoxetine, amitriptyline and haloperidol were the other drugs affecting various bleeding parameters, though the effects were less compared to the other drugs in the study.
Conclusions: Routine monitoring of bleeding parameters in patients receiving psychotropics is not warranted, but caution must be taken while prescribing these drugs, especially in groups such as patients with known blood dyscrasias or peri-operative patients.
Keywords
psychotropics, bleeding parameters, coagulopathies, prothrombin time
About this articleTitle
Effect of psychotropics on bleeding and clotting factors
Journal
Issue
Article type
Original research article
Pages
392-397
Published online
2022-10-18
Page views
1088
Article views/downloads
162
DOI
10.5603/AHP.a2022.2050
Bibliographic record
Acta Haematol Pol 2022;53(6):392-397.
Keywords
psychotropics
bleeding parameters
coagulopathies
prothrombin time
Authors
Parijat Roy
Prerna Khar
Sagar Karia
Nilesh Shah
Avinash Desousa
References (32)- Ferguson JM. SSRI antidepressant medications: adverse effects and tolerability. Prim Care Companion J Clin Psychiatry. 2001; 3(1): 22–27.
- Anderson IM, Anderson IM. SSRIS versus tricyclic antidepressants in depressed inpatients: a meta-analysis of efficacy and tolerability. Depress Anxiety. 1998; 7 Suppl 1(1): 11–17.
- Holm KJ, Markham A. Mirtazapine: a review of its use in major depression. Drugs. 1999; 57(4): 607–631.
- Abou-Setta AM, Mousavi SS, Spooner C. First-generation versus second-generation antipsychotics in adults: comparative effectiveness [Internet]. Agency for Healthcare Research and Quality, Rockville 2012: 8.
- Uçok A, Gaebel W. Side effects of atypical antipsychotics: a brief overview. World Psychiatry. 2008; 7(1): 58–62.
- Dreifuss FE, Langer DH. Side effects of valproate. Am J Med. 1988; 84(1A): 34–41.
- Gitlin M. Lithium side effects and toxicity: prevalence and management strategies. Int J Bipolar Disord. 2016; 4(1): 27.
- Halperin D, Reber G. Influence of antidepressants on hemostasis. Dialogues Clin Neurosci. 2007; 9(1): 47–59.
- Dijkstra ME, van der Weiden CFS, Schol-Gelok S, et al. Venous thrombosis during olanzapine treatment: a complex association. Neth J Med. 2018; 76(6): 263–268.
- Hergovich N, Aigner M, Eichler HG, et al. Paroxetine decreases platelet serotonin storage and platelet function in human beings. Clin Pharmacol Ther. 2000; 68(4): 435–442.
- Tham CJ, Trew M, Brager N. Abnormal clotting and production of factor VIII inhibitor in a patient treated with venlafaxine. Can J Psychiatry. 1999; 44: 923–24.
- Demet MM, Mizrak S, Esen-Danaci A. Mirtazapine-induced arthralgia and coagulopathy: a case report. J Clin Psychopharmacol. 2005; 25(4): 395–396.
- Tielens JA. Vitamin C for paroxetine- and fluvoxamine-associated bleeding. Am J Psychiatry. 1997; 154(6): 883–884.
- Dall M, Schaffalitzky de Muckadell OB, Møller Hansen J, et al. An association between selective serotonin reuptake inhibitor use and serious upper gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2009; 7(12): 1314–1321.
- 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. 2003; 163(1): 59–64.
- Turner MS, May DB, Arthur RR, et al. Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks. J Intern Med. 2007; 261(3): 205–213.
- Andrade C, Sandarsh S, Chethan KB, et al. Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and a reconsideration of mechanisms. J Clin Psychiatry. 2010; 71(12): 1565–1575.
- Hergovich N, Aigner M, Eichler HG, et al. Paroxetine decreases platelet serotonin storage and platelet function in human beings. Clin Pharmacol Ther. 2000; 68(4): 435–442.
- Serebruany VL. Selective serotonin reuptake inhibitors and increased bleeding risk: are we missing something? Am J Med. 2006; 119(2): 113–116.
- de Abajo FJ, Montero D, Rodríguez LA, et al. Antidepressants and risk of upper gastrointestinal bleeding. Basic Clin Pharmacol Toxicol. 2006; 98(3): 304–310.
- Joaquim HPG, Talib LL, Forlenza OV, et al. Long-term sertraline treatment increases expression and decreases phosphorylation of glycogen synthase kinase-3B in platelets of patients with late-life major depression. J Psychiatr Res. 2012; 46(8): 1053–1058.
- Vasiliu O. Effect of the selective serotonin reuptake inhibitors over coagulation in patients with depressive disorders — a systematic review and retrospective analysis. Romanian Journal of Military Medicine. 2019; 122(2): 7–11.
- Meijer WEE, Heerdink ER, Nolen WA, et al. Association of risk of abnormal bleeding with degree of serotonin reuptake inhibition by antidepressants. Arch Intern Med. 2004; 164(21): 2367–2370.
- May RB, Sunder TR. Hematologic manifestations of long-term valproate therapy. Epilepsia. 1993; 34(6): 1098–1101.
- Maly R, Masopust J, Hosak L, et al. Four cases of venous thromboembolism associated with olanzapine. Psychiatry Clin Neurosci. 2009; 63(1): 116–118.
- Alhenc-Gelas M, Aiach M, de Moerloose P. Venous thromboembolic disease: risk factors and laboratory investigation. Semin Vasc Med. 2001; 1(1): 81–88.
- Waage IM, Gedde-Dahl A. Pulmonary embolism possibly associated with olanzapine treatment. BMJ. 2003; 327(7428): 1384.
- Chow V, Reddel C, Pennings G, et al. Global hypercoagulability in patients with schizophrenia receiving long-term antipsychotic therapy. Schizophr Res. 2015; 162(1-3): 175–182.
- Storrie MC, Scher M, McGuire J, et al. Thrombocytopenia in the absence of leukopenia associated with the use of neuroleptics. J Clin Psychiatry. 1978; 39(10): 779–781.
- Ananth JV, Valles JV, Whitelaw JP. Usual and unusual agranulocytosis during neuroleptic therapy. Am J Psychiatry. 1973; 130(1): 100–102.
- Ekblom B, Wålinder J. Blood dyscrasia after thioridazine. Lancet. 1965; 286(7401): 36.
- Swett C. Adverse reactions to chlorpromazine in psychiatric patients. Dis Nerv Syst. 1974; 35(11): 509–511.