warfarin and Depressive-Disorder

Background There is concern that selective serotonin reuptake inhibitors ( SSRI s) substantially increase bleeding risk in patients taking anticoagulants. Methods and Results We studied 737 patients taking SSRI s in the ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Embolism and Stroke Trial in Atrial Fibrillation) trial of rivaroxaban compared with warfarin for the prevention of stroke/systemic embolism in patients with atrial fibrillation. These patients were propensity score matched 1:1 to 737 patients not taking SSRI s. The primary outcome measure was major and nonmajor clinically relevant bleeding events, the principal safety outcome in ROCKET AF . Over a mean 1.6 years of follow-up, the rate of major/ nonmajor clinically relevant bleeding was 18.57 events/100 patient-years for SSRI users versus 16.84 events/100 patient-years for matched comparators, adjusted hazard ratio ( aHR ) of 1.16 (95% confidence interval [CI], 0.95-1.43). The aHR s were similar in patients taking rivaroxaban ( aHR 1.11 [95% CI, 0.82-1.51]) and those taking warfarin ( aHR 1.21 [95% CI, 0.91-1.60]). For the rarer outcome of major bleeding, the aHR for SSRI users versus those not taking SSRI s was 1.13 (95% CI, 0.62-2.06) for rivaroxaban; for warfarin, the aHR was higher, at 1.58 (95% CI , 0.96-2.60) but not statistically significantly elevated. Conclusions We found no significant increase in bleeding risk when SSRI s were combined with anticoagulant therapy, although there was a suggestion of increased bleeding risk with SSRI s added to warfarin. While physicians should be vigilant regarding bleeding risk, our results provide reassurance that SSRI s can be safely added to anticoagulants in patients with atrial fibrillation . Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 00403767.

Topics: Aged; Anticoagulants; Anxiety Disorders; Atrial Fibrillation; Depressive Disorder; Embolism; Female; Hemorrhage; Humans; Male; Proportional Hazards Models; Risk Factors; Rivaroxaban; Selective Serotonin Reuptake Inhibitors; Stroke; Warfarin

Pharmacogenetic testing for clinical applications is steadily increasing. Correct and adequate use of pharmacogenetic tests is important to reduce unnecessary medical costs and adverse patient outcomes. This document contains recommended pharmacogenetic testing guidelines for clinical application, interpretation, and result reporting through a literature review and evidence-based expert opinions for the clinical pharmacogenetic testing covered by public medical insurance in Korea. This document aims to improve the utility of pharmacogenetic testing in routine clinical settings.

Topics: Anticoagulants; Antidepressive Agents; Antimetabolites, Antineoplastic; Antitubercular Agents; Arylamine N-Acetyltransferase; Clopidogrel; Coronary Artery Disease; Cytochrome P-450 CYP2C19; Cytochrome P-450 CYP2C9; Cytochrome P-450 CYP2D6; Depressive Disorder; Genotype; Isoniazid; Laboratories, Hospital; Methyltransferases; Pharmacogenomic Testing; Platelet Aggregation Inhibitors; Pulmonary Embolism; Ticlopidine; Tuberculosis; Vitamin K Epoxide Reductases; Warfarin

To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs).. Retrospective cohort study.. This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics).. Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions.. Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.

Topics: Aged; Alcoholism; Anticoagulants; Anxiety Disorders; Atrial Fibrillation; Depressive Disorder; Female; Humans; Male; Mental Disorders; Middle Aged; Psychotic Disorders; Retrospective Studies; Stress Disorders, Post-Traumatic; Warfarin

Selective serotonin reuptake inhibitors (SSRI) are widely prescribed. Several reports have observed an increased bleeding risk associated with SSRI use, which is hypothesized to be secondary to their antiplatelet effect.. We tested the hypothesis that SSRIs increase the risk for or potentiate the risk of hemorrhagic stroke associated with antiplatelets and anticoagulants.. In multivariate analysis, we found no increased risk associated with SSRI use for intracerebral hemorrhage (odds ratio=1.1, 95% CI: 0.7 to 1.8; P=0.63) or subarachnoid hemorrhage (odds ratio=0.6, 95% CI: 0.4 to 1.0; P=0.054). In addition, potentiation of risk with warfarin or antiplatelets was not observed.. Further studies with larger populations would be needed to exclude a small increase in intracranial hemorrhage risk with SSRI use.

Topics: Aged; Blood Coagulation; Blood Platelets; Case-Control Studies; Cerebral Hemorrhage; Depressive Disorder; Drug Synergism; Female; Humans; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Platelet Aggregation Inhibitors; Risk Factors; Selective Serotonin Reuptake Inhibitors; Serotonin; Stroke; Treatment Outcome; Warfarin

Topics: Aged; Comorbidity; Depressive Disorder; Drug Interactions; Female; Heart Diseases; Humans; Male; Selective Serotonin Reuptake Inhibitors; Warfarin

We describe our experience with six patients with atrial fibrillation (AF) during electroconvulsive therapy (ECT). In four, we observed episodic or persistent conversion of AF to normal sinus rhythm (NSR). Four patients, three with cardioversion and one without, received anticoagulation. In published case reports, ECT was successfully performed in three patients with AF without anticoagulation and in three patients with AF who received anticoagulation. In addition, 18 patients received ECT while taking concomitant anticoagulation therapy for reasons other than AF. Despite the potential risk of embolization with AF, we consider ECT may be safely administered to patients with AF. Because of the high incidence of conversion of AF to NSR, anticoagulation therapy with either warfarin or heparin is recommended.

Topics: Aged; Aged, 80 and over; Anesthesia, General; Anticoagulants; Atrial Fibrillation; Blood Pressure; Depressive Disorder; Electroconvulsive Therapy; Female; Heart Rate; Humans; Male; Middle Aged; Mood Disorders; Premedication; Warfarin

Despite studies in the early literature showing that ECT may lead to CNS bleeding, it is unclear whether unmodified ECT increases the risk for hemorrhage in patients taking anticoagulants. The authors report two cases of depressed patients who required ECT while on coumarin derivatives. Both patients were switched to heparin. Heparin's short duration of action allowed temporary discontinuation 6-8 hours prior to each ECT with return of coagulation function close to normal when the stimulus was administered. No complications were observed in any of the patients. The authors believe that this technique minimizes any possible risks from ECT in patients on anticoagulants.

Topics: Anticoagulants; Depressive Disorder; Electroconvulsive Therapy; Hemorrhage; Heparin; Humans; Male; Middle Aged; Risk; Warfarin