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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by linkadge on December 31, 2006, at 16:20:24
Not that I want to alarm anybody, but there is a group of thought which suggests SSRI's have the ability as fenfluramine did, to cause dammage to the heart.
What do you make of studies such as this?
http://circ.ahajournals.org/cgi/content/abstract/113/1/81
Linkadge
Posted by madeline on December 31, 2006, at 17:41:32
In reply to SSRI's and the heart, posted by linkadge on December 31, 2006, at 16:20:24
I really don't think there is much need to panic here.
However, during an overdose of the SSRI's especially citalopram, there can be marked EKG changes.
ALso, at really high concentrations fluoxetine and norfluoxetine can change the sodium flux in the heart.
In my opinion, as a lot of people have pointed out on this board many many times, these drugs are so widely prescribed (much more than phen-fen)that if heart valve trouble was going to be an issue, it would have shown up by now.
They may not work for all, and aside from an increase suicide risk in pediatric patients, these drugs seem pretty safe.
Posted by tensor on December 31, 2006, at 18:13:02
In reply to SSRI's and the heart, posted by linkadge on December 31, 2006, at 16:20:24
Nothing is safe, not even water. It's dangerous to live, you could die.
/Mattias
Posted by linkadge on December 31, 2006, at 20:00:34
In reply to Re: SSRI's and the heart » linkadge, posted by madeline on December 31, 2006, at 17:41:32
My concern is this. Fenfluramine supposedly caused cardiac valvulopathy by increasing serotonin activity at a certain cardiac receptor.
I think that the same thing could be happening with SSRI's as they will affect cardiac 5-ht, but that the problem might not appear till many years down the road.
Linkadge
Posted by madeline on December 31, 2006, at 20:22:53
In reply to Re: SSRI's and the heart » madeline, posted by linkadge on December 31, 2006, at 20:00:34
Yeah, I got that concern.
I'm just not that worried about it.
There may just not be that big of an effect in the periphery at the changes in concentration induced by the SSRI's.
Serotonin is also a vasoconstrictor in the periphery. It also may play a role in platelet aggregation and clotting.
We haven't seen changes in blood pressure, bleeding times or much along those lines in people on SSRI therapy.
I think it is a dilution issue.
Serotonin is concentrated at certain places in the brain. I think it is most likely diluted out in the periphery so a change in concentration (unless it is a big one - overdose range) probably won't matter that much.
If there are effects, they are very mild and subclinical.
Posted by linkadge on December 31, 2006, at 20:40:20
In reply to Re: SSRI's and the heart » linkadge, posted by madeline on December 31, 2006, at 20:22:53
But, we already know that SSRI's can increase serotonin to a significant extent in other paripherial tissue. Ie. SSRI's can increase GI problems significantly in some patients. They are not just centrally acting.
People who already posess the SS varient of the serotonin transporter might also be at more significant risk, as SS varient + SSRI would have even more diminished SERT function, making them more like the SERT knockout mice.
I don't know. It scares me. I would be frightened to take the drugs long term. Sometimes when things start to pop up its too late.
I mean we take the drugs because they cause hippocampal proliferation. Serotonin promotes proliferation in a variety of human tissues.
Would it be of suprise if they cause growth in the heart too, like fenfluramine induced structural abnormalities?I know I am paranoid.
Linkadge
Posted by Quintal on December 31, 2006, at 21:22:24
In reply to Re: SSRI's and the heart » linkadge, posted by madeline on December 31, 2006, at 20:22:53
>We haven't seen changes in blood pressure, bleeding times or much along those lines in people on SSRI therapy
Well I've seen bleeding disorders mentioned as a characteristic side effect of SSRIs here in the British National Formulary:
__________________________________________________The selective serotonin re-uptake inhibitors (SSRIs) have fewer antimuscarinic side-effects than the older tricyclics and they are also less cardiotoxic in overdosage. Therefore, although no more effective, they are preferred where there is a significant risk of deliberate overdosing or where concomitant conditions preclude the use of other antidepressants. SSRIs are also preferred to tricyclic antidepressants for depression in patients with diabetes. The SSRIs do, however, have characteristic side-effects of their own; gastro-intestinal side-effects such as nausea and vomiting are common and bleeding disorders have been reported.
http://www.bnf.org/bnf/bnf/52/3294.htm
__________________________________________________Although rare, it seems that bleeding disorders are associated with SSRIs and are cause of enough concern for the both the British Medical Association and the Royal Pharmaceutical Society of Great Britain to list it in their advice to GPs in balancing the risks of different classes of antidepressants.
Q
Posted by Phillipa on December 31, 2006, at 22:08:11
In reply to Re: SSRI's and the heart » madeline, posted by Quintal on December 31, 2006, at 21:22:24
But here in the States a lot of docs prescribe a baby aspirin a day to keep the blood thin. I would think it would help in keeping blood clots from forming. So less pumonary embolisms and clots to the heart. And my GP said I would die of stress. I think I'd rather die of a heart attack than cancer. Love Phillipa ps who knows as it's true one day it's the water the next day not enough fiber and on and on it goes. And Link I'm paranoid about meds too.
Posted by Quintal on December 31, 2006, at 22:26:37
In reply to Re: SSRI's and the heart » Quintal, posted by Phillipa on December 31, 2006, at 22:08:11
>But here in the States a lot of docs prescribe a baby aspirin a day to keep the blood thin.
They do here in the UK too and yes, aspirin too will cause bleeding problems for some people. Fish oil and vitamin E have similar blood-thinning effects. I'm not particularly paranoid about meds, just pointing out a reference to that I article I happened to remember about SSRIs and bleeding.
Q
Posted by Phillipa on December 31, 2006, at 22:39:57
In reply to Re: SSRI's and the heart » Phillipa, posted by Quintal on December 31, 2006, at 22:26:37
Quintal just my paranoia of med kicking it's ugly head. Love Jan
Posted by madeline on January 1, 2007, at 4:06:41
In reply to Re: SSRI's and the heart » madeline, posted by Quintal on December 31, 2006, at 21:22:24
Thank you for your post, There is a smattering of cases in the literature of patients (especially pediatric ones) that have popped up with bruising, while on SSRI's.
But, honestly, if you look at the side effect profile of so many drugs, bruising and GI bleeds are a side effect of them as well and are included in the prescribing info for them as well.
I think it is clear that this is not a widespread side effect of the SSRI's.
Posted by madeline on January 1, 2007, at 4:18:01
In reply to Re: SSRI's and the heart, posted by linkadge on December 31, 2006, at 20:40:20
I think a little paranoia is a good thing when it comes to drugs.
For instance, I will not take a drug unless it has been on the market for at least 10 years (no joke 10 years).
I admit, I was really lucky that prozac worked for me, because my options would have been limited had it not, but there you have it.
To me, anything before that time period is still a clinical tiral. Did you know that at work we refer to drugs that have been approved for less than 5 years as being in phase IV clinical trials?
I think you are right to question and right to read as much as you can, but read it wisely.
For what it's worth, I think you would make a great clinical researcher, your mind appears to work like one.
Maddie
Posted by ed_uk on January 1, 2007, at 4:26:02
In reply to Re: SSRI's and the heart » madeline, posted by Quintal on December 31, 2006, at 21:22:24
Hi Quintal,
There has also been concern about prescribing SSRIs in combination with aspirin or NSAIDs........
Interaction between selective serotonin reuptake inhibitors and nonsteroidal antiinflammatory drugs: review of the literature.
OBJECTIVE: To evaluate the evidence of an interaction between selective serotonin reuptake inhibitors (SSRIs) and nonsteroidal antiinflammatory drugs (NSAIDs) producing an increased risk for gastrointestinal adverse outcomes such as bleeding. METHODS: We searched MEDLINE for English-language literature published between 1966 and August 2005. All studies examining gastrointestinal adverse effects from an SSRI-NSAID combination were included. DATA SYNTHESIS: Four retrospective studies examined gastrointestinal adverse outcomes from the combination of SSRIs and NSAIDs. The risk ratio for an upper gastrointestinal bleed from this drug combination (compared with not receiving either agent) ranged from 3.3-15.6, and the risk ratio for gastrointestinal adverse effects was 12.4. Two studies found that the risk for an upper gastrointestinal bleed from the drug combination exceeded the additive risk of the agents alone. The risk ratio for an upper gastrointestinal bleed from an SSRI-aspirin interaction was 1.9-7.2. In addition, the number needed to harm in terms of an upper gastrointestinal bleed from an SSRI-NSAID combination ranged from 62-75 patient-years, and the number needed to harm for gastrointestinal adverse effects was 2 patient-years. CONCLUSION: Concurrent use of an SSRI and NSAID increases the risk of gastrointestinal adverse outcomes such as bleeding. Clinicians must take care to avoid these negative outcomes by altering NSAID or SSRI therapy, or by providing ulcer-protective drugs.
Ed
Posted by Quintal on January 1, 2007, at 11:08:48
In reply to Re: SSRI's and the heart » Quintal, posted by ed_uk on January 1, 2007, at 4:26:02
Hi ed,
Thanks for the input. Interesting, but I wonder how many UK GPs are aware of this? I bet even fewer take any notice of it.
Q
Posted by Quintal on January 1, 2007, at 11:36:19
In reply to Re: SSRI's and the heart » Quintal, posted by madeline on January 1, 2007, at 4:06:41
>But, honestly, if you look at the side effect profile of so many drugs, bruising and GI bleeds are a side effect of them as well and are included in the prescribing info for them as well.
So the problem is even more widespread than is commonly acknowledged? Bleeding disorders may be listed deep in the small print of many patient information leaflets and doctor's reference manuals but their significance is rarely considered by doctors (or 'informed consumers') when balancing the risks and benefits of these agents. Perhaps it's time we gave them more attention?
>I think it is clear that this is not a widespread side effect of the SSRI's.
Oh, I'm not too sure about that. I've had some strange experiences myself while taking SSRIs and related drugs. I had frequent heavy nosebleeds for years while taking antidepressants to the point where I was becoming anaemic. They ceased around the time I quit meds last year - not conclusive proof of causality by any means but in the light of what we're discussing here it raises many questions.
I also suffered from recurring cellulitis while taking antidepressants. I had my first episode soon after starting SSRIs and all the while I was taking them I had episodes as often as every three months needing hospital treatment. Cellulitis is very rare in people under 40 and I was 20 when it began. Subcutaneous bleeding was mentioned at one point as being a possible cause. Again this is not proof of causality yet it does raise many questions, especially since I have had no further episodes since taking my last antidepressant.
Q
Posted by linkadge on January 1, 2007, at 12:02:05
In reply to Re: SSRI's and the heart » madeline, posted by Quintal on January 1, 2007, at 11:36:19
Some researchers concluded that there was insufficant agonismt at cardiac 5-ht2b for SSRI's to pose a risk. They said that fenfuramine was a more potent agonist here. That being said though, fenfluramine caused dammage ina very short period of time. Isn't it possable that weaker serotonergic agonism at this receptor might not cause similar problems long down the road?
Since we have basically concluded that depression has little/nothing to do with sertonin reuptake.
If serotonin isn't working properly it is via different mechanism.
Linadge
Posted by ed_uk on January 1, 2007, at 13:06:11
In reply to Re: SSRI's and the heart » ed_uk, posted by Quintal on January 1, 2007, at 11:08:48
Hi Q
>Interesting, but I wonder how many UK GPs are aware of this?
Probably not many!
>I bet even fewer take any notice of it.
I agree. It always comes up on the 'interaction checker' at the pharmacy where I work but no one takes any notice - partly because half the customers take an SSRI + an NSAID/aspirin.
Patients at high risk might need additional treatment with omeprazole or lansoprazole.
Regards
Ed
Posted by ed_uk on January 1, 2007, at 13:11:02
In reply to Re: SSRI's and the heart » madeline, posted by Quintal on January 1, 2007, at 11:36:19
Hi Q
My nose bleeds easily too - I take citalopram 80mg. The thing is, I have no idea whether I would still bleed easily if I wasn't on citalopram. I've been on it for ages.
Regards
Ed
Posted by Phillipa on January 1, 2007, at 18:14:54
In reply to Re: SSRI's and the heart » linkadge, posted by madeline on January 1, 2007, at 4:18:01
Maddie that's good to know as I feel the same way. Hence trusting benzos even if I'm becoming tolerant. Love Phillipa
Posted by Quintal on January 1, 2007, at 18:44:17
In reply to Re: SSRI's and the heart, posted by linkadge on January 1, 2007, at 12:02:05
>Some researchers concluded that there was insufficient agonismt at cardiac 5-ht2b for SSRI's to pose a risk. They said that fenfuramine was a more potent agonist here. That being said though, fenfluramine caused dammage ina very short period of time. Isn't it possable that weaker serotonergic agonism at this receptor might not cause similar problems long down the road?
I don't know. I'm tempted to say the drug companies would have a good idea of this and would be taking steps to keep us safe..............then I look at Eli Lily and Zyprexa and get a little shiver.
Q
Posted by saturn on January 1, 2007, at 20:10:52
In reply to Re: SSRI's and the heart » Quintal, posted by ed_uk on January 1, 2007, at 13:11:02
I'm probably the only person in the world who's had major chest pain from SSRI's. Still can't figure that one out.
Posted by flmm on January 2, 2007, at 10:27:27
In reply to Re: SSRI's and the heart, posted by saturn on January 1, 2007, at 20:10:52
I don't know about you, but my blood pressure goes through the roof when i am NOT on ssri type meds! That IS a risk to my heart for sure. Please, can we worry about something more importent!
Posted by linkadge on January 2, 2007, at 12:05:29
In reply to Re: SSRI's Help my blood pressure, posted by flmm on January 2, 2007, at 10:27:27
Well, you don't have to worry about it, and perhaps you don't need to either.
I just think its a potential problem that needs to be investiaged further. Afterall it wasn't that long ago that fenfluramine was taken off the market, and if I am correct, that med didn't have an effect on blood pressure.
Linkadge
Posted by sdb on January 6, 2007, at 3:01:53
In reply to Re: SSRI's and the heart » linkadge, posted by madeline on December 31, 2006, at 20:22:53
serotonin is both, a vasoconstrictor or vasodilator. These properties are related to the condition of blood vessels or is dosage dependent.
kind regards
sdb
> Yeah, I got that concern.
>
> I'm just not that worried about it.
>
> There may just not be that big of an effect in the periphery at the changes in concentration induced by the SSRI's.
>
> Serotonin is also a vasoconstrictor in the periphery. It also may play a role in platelet aggregation and clotting.
>
> We haven't seen changes in blood pressure, bleeding times or much along those lines in people on SSRI therapy.
>
> I think it is a dilution issue.
>
> Serotonin is concentrated at certain places in the brain. I think it is most likely diluted out in the periphery so a change in concentration (unless it is a big one - overdose range) probably won't matter that much.
>
> If there are effects, they are very mild and subclinical.
>
>
This is the end of the thread.
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