What SSRI (Selective Serotonin Reuptake Inhibitor) to start in a patient taking Eliquis (apixaban) with a history of pulmonary embolism?

SSRI Selection for Patients Taking Eliquis with History of Pulmonary Embolism

Sertraline is the preferred SSRI for patients taking apixaban (Eliquis) with a history of pulmonary embolism due to its lower bleeding risk profile and minimal drug interactions with factor Xa inhibitors.

Rationale for SSRI Selection in Anticoagulated Patients

When selecting an SSRI for patients on anticoagulation therapy, particularly those taking direct oral anticoagulants (DOACs) like apixaban (Eliquis), the primary considerations are:

1. Bleeding Risk: All SSRIs can potentially increase bleeding risk through platelet inhibition, but to varying degrees
2. Drug Interactions: Some SSRIs may interact with apixaban through CYP3A4 and P-glycoprotein pathways
3. Efficacy for Depression/Anxiety: Primary indication effectiveness

Recommended SSRI Options (In Order of Preference)

1. Sertraline (First Choice)

   • Minimal interaction with apixaban metabolism
   • Lower bleeding risk compared to other SSRIs
   • Minimal effect on CYP3A4 enzyme system
   • Starting dose: 25-50mg daily

2. Citalopram/Escitalopram (Second Choice)

   • Low interaction potential with apixaban
   • Moderate bleeding risk
   • Starting dose: 10mg daily (escitalopram) or 10-20mg daily (citalopram)

3. Fluoxetine (Third Choice)

   • Longer half-life may be problematic if bleeding occurs
   • Moderate CYP interactions
   • Starting dose: 10-20mg daily

SSRIs to Avoid

• Paroxetine and Fluvoxamine: Strong inhibitors of CYP enzymes that may increase apixaban levels 1
• High-dose SSRIs: Higher doses of any SSRI increase bleeding risk

Monitoring Recommendations

• Baseline Assessment: Check CBC, liver function, renal function before starting
• Follow-up Monitoring:
  • Monitor for signs of bleeding (bruising, epistaxis, hemoptysis, melena)
  • Assess for drug efficacy at 2-4 weeks
  • Consider dose adjustments after 4-6 weeks if needed

Special Considerations

Bleeding Risk Management

• Start at lower doses than typically used
• Educate patient about bleeding signs/symptoms
• Consider prophylactic proton pump inhibitor if GI bleeding risk factors present

Anticoagulation Management

• Maintain regular INR monitoring if patient is transitioning between anticoagulants
• Apixaban should be maintained at standard doses (5mg twice daily) unless other indications for dose reduction exist 2
• For patients with unprovoked PE, extended anticoagulation is recommended, which increases the importance of selecting an SSRI with minimal interaction 2

Drug Interaction Considerations

• Avoid adding other medications that increase bleeding risk when possible
• If multiple antithrombotic agents are required, even greater caution with SSRI selection is warranted

Conclusion

When initiating SSRI therapy in patients taking apixaban with a history of PE, sertraline represents the safest first-line option due to its favorable pharmacokinetic profile and minimal interaction with factor Xa inhibitors. Start at a low dose (25mg daily) and titrate gradually while monitoring for signs of bleeding or therapeutic failure.