Key points:
- Among older people treated with SSRIs, there was a dose-response
relationship with Fluoxetine use and increased risk of UGIB.
- The increased odds of UGIB was only observed among current fluoxetine
users.
- As SSRI use increases with age, careful considerations in treatment
dosage are needed when providing care to older people.
INTRODUCTION
Depression is common in older adults. The prevalence rates of depressive
symptom in population aged ≥65 years vary widely across countries,
ranging from 7.2% to 49%[1]. Depressed older individuals
experience mood disturbance from multiple somatic complaints[2] and
have significant mobility-related disabilities and poor prognosis[3,
4]. Therefore, appropriate intervention should be provided to these
patients, and medical therapy with antidepressants is generally
suggested.
Selective serotonin reuptake inhibitors (SSRIs) are preferred over other
classes of antidepressants such as tricyclic antidepressants or
monoamine oxidase inhibitors as they are equally effective and have
lower side effects[5]. They are now prescribed as first-line
treatment in older adults with depression[6]. However, the risk of
upper gastrointestinal bleeding (UGIB) caused by SSRIs has gained much
public attention because of its impact on platelet aggregation[7],
which can lead to bleeding events[8].
Although several studies have consistently shown that SSRI use, their
dosages, and duration of treatments are associated with risk of
UGIB[8-17], these studies did not focus on older people[8, 9, 11,
13-17] and did not provide information about the risks associated with
the doses of each individual drug[8, 15, 17]. Older people are more
likely to have multiple chronic health conditions, tend to be treated
with multiple medicine, and are possibly more vulnerable to adverse
events associated with overtreatment[18, 19]. Furthermore, older age
is significantly associated with increased mortality, especially in
patients with UGIB, and co-morbidities along with concomitant medicine
use can worsen the bleeding events[12, 13, 20]. Therefore, we aimed
to evaluate the association between use of individual SSRI drugs and
risk of UGIB, and quantify the risks associated with treatment doses.
METHODS