Warfarin and Antidepressants: Happiness Without Hemorrhaging

Overview

Journal Psychiatry (Edgmont)

Specialty Psychiatry

Date 2009 Sep 3

PMID 19724766

Citations 15

Authors

Randy A Sansone

Lori A Sansone

Affiliations

Soon will be listed here.

Abstract

Warfarin, a commonly prescribed anticoagulant, has a very narrow therapeutic index. Because a multitude of drugs may potentially alter warfarin levels, primarily through the cytochrome P-450 isoenzyme system, in this edition of The Interface, we explore drug interactions between warfarin and the antidepressants. According to the available data, sertraline and citalopram appear to be the safest antidepressants to use in patients on warfarin, whereas fluvoxamine and fluoxetine pose the highest potential risks. The remaining antidepressants appear to lie somewhere in between, with most having little empirical data to guide the practitioner other than the potential interactions of these drugs and warfarin in the cytochrome P-450 isoenzyme system.

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References

Yap K, Low S . Interaction of fluvoxamine with warfarin in an elderly woman. Singapore Med J. 1999; 40(7):480-2. View

Bannister S, Houser V, Hulse J, Kisicki J, Rasmussen J . Evaluation of the potential for interactions of paroxetine with diazepam, cimetidine, warfarin, and digoxin. Acta Psychiatr Scand Suppl. 1989; 350:102-6. DOI: 10.1111/j.1600-0447.1989.tb07186.x. View

Hemeryck A, De Vriendt C, Belpaire F . Inhibition of CYP2C9 by selective serotonin reuptake inhibitors: in vitro studies with tolbutamide and (S)-warfarin using human liver microsomes. Eur J Clin Pharmacol. 1999; 54(12):947-51. DOI: 10.1007/s002280050580. View

Apseloff G, Wilner K, Gerber N, Tremaine L . Effect of sertraline on protein binding of warfarin. Clin Pharmacokinet. 1997; 32 Suppl 1:37-42. DOI: 10.2165/00003088-199700321-00006. View

Loomis C, Racz W . Drug interactions of amitriptyline and nortriptyline with warfarin in the rat. Res Commun Chem Pathol Pharmacol. 1980; 30(1):41-58. View

Preskorn S, Borges-Gonzalez S, Flockhart D . Clinically relevant pharmacology of neuropsychiatric drugs approved over the last three years: Part II. J Psychiatr Pract. 2006; 12(5):312-6. DOI: 10.1097/00131746-200609000-00006. View

Woolfrey S, Gammack N, Dewar M, Brown P . Fluoxetine-warfarin interaction. BMJ. 1993; 307(6898):241. PMC: 1678114. DOI: 10.1136/bmj.307.6898.241-b. View

Glueck C, Khalil Q, Winiarska M, Wang P . Interaction of duloxetine and warfarin causing severe elevation of international normalized ratio. JAMA. 2006; 295(13):1517-8. DOI: 10.1001/jama.295.13.1517. View

Priskorn M, Sidhu J, Larsen F, Davis J, Khan A, Rolan P . Investigation of multiple dose citalopram on the pharmacokinetics and pharmacodynamics of racemic warfarin. Br J Clin Pharmacol. 1997; 44(2):199-202. PMC: 2042822. DOI: 10.1046/j.1365-2125.1997.00628.x. View

10.

Sayal K, McConnell H, Taylor D . Psychotropic interactions with warfarin. Acta Psychiatr Scand. 2000; 102(4):250-5. DOI: 10.1034/j.1600-0447.2000.102004250.x. View

11.

Limke K, Shelton A, Elliott E . Fluvoxamine interaction with warfarin. Ann Pharmacother. 2002; 36(12):1890-2. DOI: 10.1345/aph.1C112. View

12.

Spina E, Santoro V, DArrigo C . Clinically relevant pharmacokinetic drug interactions with second-generation antidepressants: an update. Clin Ther. 2008; 30(7):1206-27. DOI: 10.1016/s0149-2918(08)80047-1. View

13.

Schmider J, Greenblatt D, von Moltke L, Karsov D, Shader R . Inhibition of CYP2C9 by selective serotonin reuptake inhibitors in vitro: studies of phenytoin p-hydroxylation. Br J Clin Pharmacol. 1998; 44(5):495-8. PMC: 2042866. DOI: 10.1046/j.1365-2125.1997.00601.x. View

14.

Monastero R, Camarda R, Camarda C . Potential drug-drug interaction between duloxetine and acenocoumarol in a patient with Alzheimer's disease. Clin Ther. 2008; 29(12):2706-9. DOI: 10.1016/j.clinthera.2007.12.026. View

15.

Dent L, Orrock M . Warfarin-fluoxetine and diazepam-fluoxetine interaction. Pharmacotherapy. 1997; 17(1):170-2. View

16.

Ford M, Anderson M, Rindone J, Jaskar D . Lack of effect of fluoxetine on the hypoprothrombinemic response of warfarin. J Clin Psychopharmacol. 1997; 17(2):110-2. DOI: 10.1097/00004714-199704000-00009. View

17.

Pond S, Graham G, Birkett D, Wade D . Effects of tricyclic antidepressants on drug metabolism. Clin Pharmacol Ther. 1975; 18(2):191-9. DOI: 10.1002/cpt1975182191. View

18.

Claire R, Servis M, Cram Jr D . Potential interaction between warfarin sodium and fluoxetine. Am J Psychiatry. 1991; 148(11):1604. DOI: 10.1176/ajp.148.11.1604a. View

19.

Brosen K, Naranjo C . Review of pharmacokinetic and pharmacodynamic interaction studies with citalopram. Eur Neuropsychopharmacol. 2001; 11(4):275-83. DOI: 10.1016/s0924-977x(01)00101-8. View