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<p class="ltrs-br-ltr-br-title"><span class="bold">Mirtazapine-Induced Epistaxis in an Australian Indigenous Man</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> It is well known that serotonin reuptake inhibitors (SSRIs) can cause abnormal bleeding by decreasing the availability of serotonin within the platelet and, in turn, inhibiting platelet aggregation and blocking the coagulation cascade.<span class="htm-cite"><a href="#ref1">1</a></span> If there is a risk of abnormal bleeding, mirtazapine and bupropion are generally considered to be safer treatment options because they lack the serot<a id="_idTextAnchor000"></a>onin reuptake mechanism.<span class="htm-cite"><a href="#ref2">2</a></span> We present the case of an 18-year-old North Australian indigenous man, with no prior history of bleeding disorder, who developed frequent epistaxis after starting mirtazapine.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report:</span> An 18-year-old man was admitted to the hospital during the first episode of major depressive disorder (<span class="italic">DSM-5</span> criteria). He was successfully treated with mirtazapine 30 mg and discharged home with a plan for a follow-up visit at a local mental health clinic. At follow-up 4 weeks later, he complained of experiencing 6 episodes of epistaxis since discharge from the hospital. He denied any trauma to the body and had no personal or family medical history of bleeding disorders or nasopharyngeal pathology. He was not taking any other medication, including herbal products or health supplements. After completing a detailed medical history and a thorough physical examination, it was established that mirtazapine was the likely cause of the bleeding. He was advised to stop taking mirtazapine. In the following 4 weeks, he had only 1 more bleed, which occurred 2 days after stopping the medication. Weekly sessions of cognitive-behavioral therapy were continued at the clinic for residual depressive symptoms.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text">Mirtazapine is an antagonist at the α<span class="subscript">2</span>-adrenergic autoreceptor and heteroreceptor and 5-HT<span class="subscript">2</span> and 5-HT<span class="subscript">3</span> receptors. It is possible that the blockade of the 5-HT<span class="subscript">2A</span> receptor increases bleeding risk by decreasing platelet aggregation.<span class="htm-cite"><a href="#ref3">3</a></span></p>
<p class="ltrs-br-ltr-br-body-text">In the above-mentioned case, there were no identifiable preexisting risk factors for abnormal bleeding with mirtazapine therapy. Although epistaxis is mentioned as an infrequent side effect in the prescribing information for mirtazapine,<span class="superscript">4</span> it is often a favored medication in consultation-liaison psychiatry because of its perceived safety with regard to bleeding disorders. Mirtazapine is often prescribed to surgical patients or others at risk for bleeding disorders. Mindful prescribing behavior, education of patients, and careful monitoring for specific side effects including risk of bleeding are good clinical practices when prescribing mirtazapine. The exact causation between non-SSRI antidepressants and bleeding is not yet fully understood. Larger-scale studies controlling for confounding factors are necessary to establish a correlation between mirtazapine and abnormal bleeding.</p>
<p class="references_references-heading"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a><span class="htm-ref"> 1.	</span>Anglin R, Yuan Y, Moayyedi P, et al. Risk of upper gastrointestinal bleeding with selective serotonin reuptake inhibitors with or without concurrent nonsteroidal anti-inflammatory use: a systematic review and meta-analysis. <span class="italic">Am J Gastroenterol</span>. 2014;109(6):811–819. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=24777151&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1038/ajg.2014.82"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref2"></a><span class="htm-ref"> 2.	</span>Jeong B-O, Kim S-W, Kim S-Y, et al. Use of serotonergic antidepressants and bleeding risk in patients undergoing surgery. <span class="italic">Psychosomatics</span>. 2014;55(3):213–220. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=24314591&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1016/j.psym.2013.08.011"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref3"></a><span class="htm-ref"> 3.	</span>Anttila SA, Leinonen EV. A review of the pharmacological and clinical profile of mirtazapine. <span class="italic">CNS Drug Rev</span>. 2001;7(3):249–264. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11607047&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
https://doi.org/10.1111/j.1527-3458.2001.tb00198.x"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9">	4.	Remeron<span class="italic">® </span>(mirtazapine) tablets. <a href="
https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/020415s019,021208s010lbl.pdf" target=_blank">
https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/020415s019,021208s010lbl.pdf</a>. Accessed September 26, 2018.</p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Tamoor Mirza, FRANZCP</span><span class="superscript">a</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Muhammad Hassan Majeed, MD</span><span class="superscript">b</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:Hassan.Majeed@icloud.com">
Hassan.Majeed@icloud.com</a></p>
<p class="end-matter"><span class="superscript">a</span>Headspace Youth Early Psychosis Program, Darwin, NT, Australia</p>
<p class="end-matter"><span class="superscript">b</span>Department of Psychiatry, Natchaug Hospital, Mansfield Center, Connecticut</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding support:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Patient consent:</span> Consent was obtained from the patient to publish the case, and information has been de-identified to protect anonymity.</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> October 25, 2018.</p>
<p class="end-matter"><span class="italic">Prim Care Companion CNS Disord 2018;20(5):18l02288</span></p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Mirza T, Majeed MH. Mirtazapine-induced epistaxis in an Australian indigenous man. <span class="italic">Prim Care Companion CNS Disord.</span> 2018;20(5):18l02288.</p>
<p class="doi-line"><span class="bold-italic">To share:</span>
https://doi.org/<span class="doi">10.4088/PCC.18l02288</span></p>
<p class="end-matter"><span class="italic">© Copyright 2018 Physicians Postgraduate Press, Inc.</span></p>
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