Selective serotonin reuptake inhibitors and perioperative bleeding in endoscopic dacryocystorhinostomy

Sir,

During a recent endoscopic dacryocystorhinostomy procedure on a patient taking selective serotonin reuptake inhibitors (SSRIs), we noticed engorgement of the nasal mucosa as well as severe early post-op epistaxis. We write to remind readers of the potential association between SSRIs and perioperative hemorrhage.

SSRIs (e.g. Citalopram, Fluoxetine, Fluvoxamine, and Sertraline) are commonly used to treat mood disorders such as depression, anxiety, and obsessive–compulsive disorders. Their popularity in the treatment of mood disorders stems from their side effect profile, which is better tolerated than the classic treatments (monoamine oxidase inhibitors, tricyclic antidepressants, etc).

One of the side effects of SSRIs of particular interest to us is the increased risk of bleeding perioperatively. It has already been documented that SSRIs increase the risk of gastrointestinal bleeding¹ and intracranial hemorrhage.² de Abajo³ summarizes the mechanism by which the SSRIs potentiate bleeding. Platelets cannot synthesize serotonin; rather, serotonin is stored in platelets and released by certain stimuli to induce vasoconstriction and platelet activation, and to enhance fibrin formation. This important neurotransmitter also helps in generating coated platelets, a subgroup of platelets with important procoagulant activity. As SSRIs inhibit the serotonin transporter, which is responsible for the uptake of serotonin into platelets, it could be predicted that SSRIs would deplete platelet serotonin, leading to a reduced ability to form clots and a subsequent increase in the risk of bleeding.

Although some clinical practice references suggest holding SSRIs for 2 or more weeks before surgery, it is difficult to frame a detailed strategy based on the available evidence.^{4, 5} Discontinuing SSRIs could lead to discontinuation syndrome, increased sensitivity to pain, and relapsing depression postoperatively. Furthermore, although the morbidity may be greater in patients under SSRIs, the mortality is still quite low.⁵ Consultation with a psychiatrist is recommended when there is high risk of morbidity from perioperative bleeding.

We write to remind readers to consider this potential association between the use of SSRIs and increased risk of hemorrhage, especially during the consent process for lacrimal surgery.

The authors declare no conflict of interest.