Use of serotonergic antidepressants and bleeding risk in patients undergoing surgery

Background: Serotonergic antidepressants (SADs) are associated with increased bleeding risk.

Objectives: To develop optimal guidelines for the usage of antidepressants in the perioperative period, this review of the bleeding risk associated with SADs was conducted.

Methods: A total of 10 original articles describing the relationship between SAD use and perioperative bleeding published in English before June 2013 were selected and reviewed.

Results: A total of 6 studies showed positive associations between SAD use and perioperative bleeding. In particular, SAD use before orthopedic or breast surgery was associated with a tendency toward increased intraoperative or postoperative bleeding (i.e., increased need for transfusion during surgery, greater amount of intraoperative blood loss, bleeding events requiring intervention, or reoperation owing to postoperative bleeding). However, 3 studies among SAD users undergoing coronary artery bypass grafting and 1 study in SAD users undergoing facial surgery did not report an increased risk for postoperative bleeding.

Conclusions: The risks and benefits of SAD use should be weighed in all patients undergoing surgical operations. Physicians may consider planned discontinuation of SADs 2 weeks before the operation in patients with a high risk of bleeding but in the stable phase of depression. SAD discontinuation syndrome should be managed appropriately. If, despite the expected exacerbation of depression after discontinuation of antidepressants, discontinuation of SADs is nonetheless required because of the patient's clinical risk of bleeding, changing to an antidepressant that does not, or less potently, inhibits serotonin reuptake (e.g., bupropion or mirtazapine) can be considered.