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Menopause - Management
What issues do I need to consider before prescribing a selective serotonin reuptake inhibitor?

  • The most common adverse effects associated with selective serotonin reuptake inhibitors (SSRIs) are gastrointestinal effects (nausea and diarrhoea), central nervous system effects (dizziness, agitation, insomnia, and tremor), and sexual dysfunction [Taylor et al, 2005].
  • Observational studies have shown that SSRIs increase the risk of upper gastrointestinal bleeding, probably by altering platelet function [de Abajo et al, 1999; van Walraven et al, 2001; Dalton et al, 2003; Meijer et al, 2004]. This observed increase in risk may also apply to other types of bleeding:
    • This risk is increased in people who are also taking low-dose aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) [Dalton et al, 2003]. Consider gastroprotection for all people who are prescribed both an SSRI and an NSAID or aspirin [Paton and Ferrier, 2005].
    • This increased risk may also apply to very old people or those with a history of gastrointestinal bleeding. Consider using an antidepressant with a low affinity for the serotonin transporter [Paton and Ferrier, 2005].
    • People receiving warfarin should receive careful coagulation monitoring when treatment with an SSRI is initiated or stopped.
  • Extrapyramidal symptoms are relatively rare and seem to be most common with paroxetine [CSM, 2000].
  • Co-administration of SSRIs with other serotonergic drugs (e.g. tramadol, triptans) or with dopaminergic drugs (e.g. selegiline) may also increase the risk of serotonin syndrome, and close monitoring is advised [Stockley, 2002].
  • SSRIs have a low proconvulsant effect, the seizure risk being dose-related, and are a good choice of antidepressant for people with epilepsy. However, fluoxetine and paroxetine (and to a lesser extent sertraline) can increase serum levels of phenytoin and carbamazepine through inhibition of hepatic enzymes. Serum phenytoin levels should be monitored and the dosage adjusted accordingly when starting, stopping, or changing the dose of these SSRIs. Citalopram is a weak enzyme inhibitor and has a low potential for clinically significant interactions [Taylor et al, 2005].

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