Discussion Forum for 3/8/18

Thank you Seth for the case studies!

Discuss how and when you would intervene (if any) in the following example and situations:

62F on fluoxetine 40mg x 5 months for PTSD/MDD, warfarin x 4 years for A.fib, stroke. Labs WNL, INR is therapeutic.

Situation 1: New complaints of bleeding of gums for 10-20 minutes

Interventions:  Review any changes to medications, changes in dental care, brushing and flossing techniques. Potentially consult with dental provider if, for example, pt is overdue for cleaning and increase bleeding is related to poor dental hygiene would pursue this first.  Review efficacy of fluoxetine in treating pt's PTSD/MDD symptoms, how well controlled PTSD/MDD is, what, if any, additional therapy pt is engaged in for PTSD/MDD.  Initiate and/or increase use of psychotherapy and/or group therapy to address symptoms.  Trial decreased dose of fluoxetine at 35mg, continue to assess symptoms and bleeding on an ongoing basis to assess whether more aggressive interventions are warranted, reassess psych sx in 4 wks (due to fluoxetine's long half-life, sooner for any acute increase in PTSD/depressive sx). 

Situation 2: Pale, poor energy, falls 2-3x/month

Interventions: Redraw CBC to check for anemia and verify coags, check for any other signs of internal bleeding, ask about bruising post falls. Review/check for any dietary changes (iron deficiency anemia), hydration status, brief neuro exam, reassess PTSD/MDD symptoms to assess whether energy is r/t depressive sx. If all are negative, initiate and/or increase use of psychotherapy and/or group therapy to address symptoms and consider trial decreased fluoxetine dose as above, would hold off unless there was additional, more definitive evidence of bleeding. Nutritionist, PT and OT consults if indicated.

Situation 3: Reports dark tarry stools since dose increase of fluoxetine

Interventions: Order fecal occult blood test to verify presence of blood in stool.  Review medications and/or diet to determine if there are changes that could account for dark, tarry stool, check for any other signs of internal bleeding.  If there fecal occult is positive and there was nothing to suggest an alternate reason for blood in stool, trial decreased fluoxetine back to previous dose (at which pt did not experience dark tarry stools), reassess at 4 wks as above.  Refer to/initiate therapy--individual, group.

Situation 4: New complaints of bruises lasting at least 1 week and are slow to completely heal

Interventions: Better characterize bruising--cause/s, severity, onset, location. Assess neuro if bruising is possibly r/t neuro status/changes. Recheck labs.  Again, if all negative trial decreased fluoxetine, refer to therapy--individual and group, reassess in 4 wks (sooner for any acute increase in depressive sx).

For all I would have them check INR more frequently as use of SSRIs has been correlated with increased variability in INR which has been thought to account for bleeding episodes (Quinn et al., 2014).

U.S. Department of Veterans Affairs, Health Care PTSD: National Center for PTSD. (2017). Professional Treatment Overview. Retrieved from https://www.ptsd.va.gov/professional/treatment/overview/index.asp

Quinn, G. R., Singer, D. E., Chang, Y., Go, A. S., Borowsky, L. H., Udaltsova, N., & Fang, M. C. (2014). Effect of Selective Serotonin Reuptake Inhibitors on Bleeding Risk in Patients with Atrial Fibrillation Taking Warfarin. The American Journal of Cardiology, 114(4), 583–586. https://ucsf.idm.oclc.org/login?url=http://doi.org/10.1016/j.amjcard.2014.05.037

Thank you, Seth, for this case studies. 

Jamie has included very appropraite treatments and interventions in regards to the bleeding. 

In regards to this patient and upon doing research with antidepressants and warfarin therapy, I found that there are certain antidepressants that pose minimal or high risk when combined with warfarin therapy. According to Sansone & Sansone (2009), sertraline and citalopram appear to be the safest antidepressants to use in patients with warfarin. Fluvoxamine and fluoxetine pose the highest potential risks as it inhibits warfarin metabolism through the isoenzymes in the cytochrome P-450. The other antidepressants fall in between. 

As for me, I would start to decrease and taper the patient off fluoxetine and change the antidepressant to either sertraline or citalopram. While a taper process is in place, it is important the patient seeks psychotherapy to help alleviate and gain/enhance coping skills as a medication change is occurring. I think immediately decreasing the dose from 40mg to 20mg, then discontinuing would be safe due to the long half-life of fluoxetine. I would start sertraline at 25mg 1 tab daily. One study shows that fluoxetine can be stopped or taper the dose if it is greater than 40mg, wait 7 days for a "wash out" period and then start a low dose of SSRI (Keks, Hope, Keogh, 2016). It is also important to watch for serotonin syndrome when stopping one antidepressant with a long half life and adding a new one. Also, given the fact that the patient is 62 years old, prozac is not usually recommended to the elderly population. 

After stopping prozac and starting the patient on sertraline, labs would be beneficial to redraw. Continuing to monitor the bleeding is essential. We can also educate the patient to reduce foods that can cause increase bleeding. 

Reference 

Keks, N., Hope, J., & Keogh, S. (2016). Switching and stopping antidepressants. Australian Prescriber, 39(3), 76-83. https://ucsf.idm.oclc.org/login?url=http://doi.org/10.18773/austprescr.2016.039

Sansone, R.A., & Sansone, L.A. (2009). Warfarin and antidepressants: happiness without hemorrhaging. Psychiatry (Edgmont), 6(7), 24-29. 

62F on fluoxetine 40mg x 5 months for PTSD/MDD, warfarin x 4 years for A.fib, stroke. Labs WNL, INR is therapeutic.

Situation 1: New complaints of bleeding of gums for 10-20 minutes

            In this situation I would likely require more information as to the setting of the gum bleeding. Is this after brushing with a hard toothbrush? Eating hard crackers? 

Situation 2: Pale, poor energy, falls 2-3x/month

            As Jamie, I would re-draw my CBC. However, the presence or absence anemia could be a red herring, and I would order further bloodwork, including B12, thyroid, sodium. I would instruct the patient to see her PCP to get a full workup if none of my labs came back with an obvious cause.

Situation 3: Reports dark tarry stools since dose increase of fluoxetine

            In this situation I would have the patient self-report to the ER. Working in an intensive care unit, I can attest that GI bleeders are the people who can present with few symptoms beyond tarry stools before they immediately decompensate and require a rapid transfusion machine

Situation 4: New complaints of bruises lasting at least 1 week and are slow to completely heal

            In all of these cases, I would consider the response to fluoxetine. If the patient were previously very unstable and was now functioning well, I would be reticent to change the fluoxetine and might consider the severity of the increased bleeding (IE gums with heavy toothbrushing vs GI bleed) before doing so.