Can citalopram (selective serotonin reuptake inhibitor) cause bruising?

Citalopram and Bruising: Risk Assessment and Management

Citalopram can cause bruising due to its effects on platelet function and increased bleeding risk, particularly when combined with other medications that affect coagulation. This risk is well-documented in clinical guidelines and FDA labeling.

Mechanism of Action and Bleeding Risk

Selective serotonin reuptake inhibitors (SSRIs) like citalopram increase the risk of bleeding through several mechanisms:

• Inhibition of serotonin reuptake into platelets, affecting platelet aggregation 1
• Direct inhibition of platelet adhesion to collagen and fibrinogen surfaces 2
• Possible immune-mediated thrombocytopenia in rare cases 3

The FDA drug label for citalopram specifically warns about abnormal bleeding:

"SSRIs and SNRIs, including citalopram tablets, may increase the risk of bleeding events. Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs, warfarin, and other anticoagulants may add to the risk." 4

Evidence Strength and Clinical Significance

The American Family Physician guidelines note that gastrointestinal bleeding has an odds ratio of 1.2 to 1.5 with SSRI use, with risk increasing when combined with:

• NSAIDs
• Antiplatelet medications
• Anticoagulants 1

This bleeding risk can manifest as:

• Ecchymoses (bruising)
• Hematomas
• Epistaxis (nosebleeds)
• Petechiae
• In severe cases, life-threatening hemorrhages 4

Risk Factors for Increased Bruising

The risk of bruising and bleeding is higher in:

1. Elderly patients 1
2. Patients taking multiple medications that affect coagulation 4
3. Patients with liver impairment (due to decreased citalopram clearance) 4
4. Patients with pre-existing bleeding disorders

Management Recommendations

For patients experiencing bruising while on citalopram:

1. Assess medication interactions:

   • Review concurrent use of NSAIDs, aspirin, warfarin, or other anticoagulants 4
   • Consider the cumulative effect of multiple medications on bleeding risk

2. Consider dosage adjustment:

   • Lower doses may reduce bleeding risk while maintaining antidepressant efficacy
   • Hepatic impairment requires lower maximum dosage 4

3. Monitor for serious bleeding signs:

   • Increased bruising may precede more serious bleeding events
   • Patient education about warning signs is essential

4. Alternative options:

   • If bruising is problematic, consider switching to antidepressants with lower bleeding risk profiles

Clinical Pearls and Pitfalls

• Don't assume all bruising is benign: While minor bruising is common with SSRIs, extensive bruising may signal a more serious bleeding risk
• Avoid premature discontinuation: Abrupt discontinuation of citalopram can lead to withdrawal symptoms 4
• Laboratory monitoring: Consider platelet count and coagulation studies in patients with significant bruising
• Patient education: Inform patients about the increased bleeding risk and advise them to report unusual bruising or bleeding

Conclusion

Bruising is a recognized side effect of citalopram due to its impact on platelet function and hemostasis. The risk increases with concomitant use of other medications affecting coagulation. While most cases are mild, clinicians should monitor for signs of more serious bleeding and adjust treatment accordingly.