From the FDA Drug Label
The safety profile observed with sertraline treatment in patients with major depressive disorder, OCD, panic disorder, PTSD, PMDD and social anxiety disorder is similar (including Torsade de Pointes arrhythmias) (including reversible cerebral vasoconstriction syndrome and Call-Fleming syndrome) hypothyroidism, agranulocytosis, aplastic anemia and pancytopenia, leukopenia, thrombocytopenia, lupus-like syndrome, serum sickness, diabetes mellitus, hyperglycemia, galactorrhea, hyperprolactinemia, extrapyramidal symptoms, oculogyric crisis, serotonin syndrome, psychosis, pulmonary hypertension, severe skin reactions, which potentially can be fatal, such as Stevens-Johnson syndrome, vasculitis, photosensitivity and other severe cutaneous disorders, rare reports of pancreatitis, and liver events-clinical features (which in the majority of cases appeared to be reversible with discontinuation of sertraline) occurring in one or more patients include: elevated enzymes, increased bilirubin, hepatomegaly, hepatitis, jaundice, abdominal pain, vomiting, liver failure and death.
A safe alternative to consider for a patient with aplastic anemia and thrombocytopenia is sertraline 1, as it has a similar safety profile to other treatments for psychiatric disorders, and the label does mention aplastic anemia and thrombocytopenia as potential adverse effects, but does not necessarily contraindicate its use in these conditions.
- Key points to consider when switching to sertraline:
- Monitor the patient's blood cell counts closely for any signs of worsening aplastic anemia or thrombocytopenia.
- Be aware of the potential for sertraline to cause liver enzyme elevations, and monitor the patient's liver function tests regularly.
- Adjust the dose of sertraline as needed to minimize the risk of adverse effects.
From the Research
For a patient with aplastic anemia and thrombocytopenia who needs to discontinue Lexapro (escitalopram), sertraline would not be a safe alternative antidepressant to consider due to its potential to cause bleeding, as reported in a case study 2. Instead, bupropion (Wellbutrin) could be considered as a safe alternative, despite a recent case report of bupropion-induced pancytopenia 3, the overall evidence still suggests it is a safer option compared to other antidepressants that may exacerbate thrombocytopenia. Starting at 150 mg once daily of the extended-release formulation for one week, then increasing to 150 mg twice daily if tolerated, would be an appropriate regimen. When switching, it's essential to cross-taper gradually - start bupropion while slowly reducing Lexapro over 1-2 weeks to minimize discontinuation symptoms. Bupropion works differently than SSRIs like Lexapro, affecting dopamine and norepinephrine rather than serotonin, which explains its favorable hematologic profile. Monitor the patient's blood counts regularly during the transition. Be aware that bupropion may cause insomnia, agitation, or increased blood pressure, so morning dosing is preferred. Bupropion is also contraindicated in patients with seizure disorders or eating disorders, so assess for these conditions before initiating therapy. It's also important to note that the patient's aplastic anemia and thrombocytopenia should be managed according to current treatment guidelines, which may include immunosuppressive therapy or bone marrow transplantation, as outlined in a recent review of aplastic anemia treatment options 4. In terms of thrombocytopenia, it's a condition that can be caused by various factors, including aplastic anemia, as discussed in a study on clinical variations between different causes of thrombocytopenia 5. However, the primary concern in this case is finding a safe alternative to Lexapro that does not exacerbate the patient's thrombocytopenia, making bupropion a preferable choice despite its potential risks, as highlighted in a case report of bupropion-induced severe leukocytosis 6.