Introduction: Antidepressants have a vital role in treating post-stroke depression and improving motor recovery. SSRI/SNRI’s have antiplatelet effects, possibly increasing the risk of hemorrhage when taken with anticoagulants. The impact of concomitant SSRI/SNRI use on patients taking different anticoagulants for atrial fibrillation is not known.
Methods: Data included Medicare Part A, B, and D claims for 2010-2013. Patients 66 years or older, with a new diagnosis of AF who initiated warfarin, dabigatran (150 mg bid) or rivaroxaban (20 mg od) within 90 days of diagnosis were included. SSRI/SNRI use was identified using prescription claims within +/- 90 days of anticoagulation initiation. Patients taking warfarin, dabigatran, and rivaroxaban with concurrent SSRI/SNRI were matched using a 3-way propensity algorithm. The relative hazards of death, stroke, GI hemorrhage, and other major hemorrhage were compared between anticoagulants.
Results: We identified10,773 patients with SSRI/SNRI use, and 37,278 without SSRI/SNRI use. At baseline, patients who received SSRI/SNRIs were more likely than other patients to have several comorbid conditions, including coronary artery disease, liver disease, kidney disease, previous hemorrhage, and previous stroke. In matched samples of patients taking SSRI/SNRI, dabigatran users had the lowest incidence of any hemorrhage, with Hazard Ratio [HR]=0.78 (p=0.07) relative to warfarin; 0.68 (p=0.01) relative to rivaroxaban. Non-GI-hemorrhage was less likely with both dabigatran and rivaroxaban, compared to warfarin, while GI hemorrhage was most likely with rivaroxaban. The risk of death was significantly lower with dabigatran (HR 0.60; p<0.001) and rivaroxaban (HR 0.67; p=0.007), compared to warfarin. There was no difference in stroke incidence by anticoagulant type.
Conclusion: In patients with AF and concomitant SSRI/SNRI use, dabigatran has the lowest risk of hemorrhage and mortality.