Oct 04, 2017
Karyn asked
Hello, I take Clopidogrel due to a stroke and I need to take an antidepressant. My GP has said that all anti-depressants cause internal bleeding when taken with Clopidogrel. I need some help!
Answer
Many antidepressant medications do in fact interact with Plavix (Clopidogrel) as your GP has stated, but the interaction only exists with certain classes. Most notably, any class of medication that affects the serotonin will 'interact' with a blood thinner.
Serotonin is most commonly thought of and recognized as a neurotransmitter, but in fact, most of the body’s serotonin is found outside of the central nervous system and serotonin is a major component of blood platelets. When platelets are activated, serotonin is released into the blood circulation and stimulate clotting (platelet aggregation).
The most commonly prescribed class of antidepressants is the SSRI (Selective Serotonin Reuptake Inhibitor) class. Medications in this class include Zoloft (Sertraline), Paxil (Paroxetine) and Prozac (Fluoxetine). SSRI drugs lead to decreased concentrations of serotonin within the platelet, and block platelet aggregation. This could increase the risk of bleeding as you mentioned in your question. Really, any medication that affects serotonin can be a problem when taking blood thinners, not just SSRIs. Other antidepressant medications that affect serotonin include SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors), Trazodone and the Tricyclic class of medications.
It's important to know that that SSRIs or SNRIs can still be used if needed, even though there may be a slight increased risk of bleeding. Studies show that depression itself increases risk of cardiovascular events and can also lead to poor adherence to medications as well as a poor diet among other things. Typically patients should be instructed to monitor for signs and symptoms of bleeding while taking an SSRI at the same time with an antiplatelet medication and to promptly report any bleeding events to the practitioner.
If a practitioner does want to avoid medications that are known to potentially cause issues, there are antidepressant medications that don't affect serotonin (or affect serotonin in a mild way) and are generally considered okay to use with blood thinners. Wellbutrin (Buproprion) is a good example. Wellbutrin doesn't have any significant influence on serotonin and may be a good option for those on certain blood thinners. Another possible option is mirtazapine as it also doesn't appear to increase bleeding risk.
In addition, it may be beneficially to have a patient take a medication that decrease stomach acid. A 2008 case-control study showed that the risk of a GI bleed was attenuated if acid-suppressive therapy (e.g. PPI medication) was used. Another study in 2014 also found that risk was avoided or at the least greatly decreased with use of acid-suppressive therapy.
