Risk of Spontaneous Bruising with Concomitant Use of Nonsteroidal Antiinflammatory Drugs and Citalopram

Objective: To report a case of spontaneous bruising with concomitant use of nonsteroidal antiinflammatory drugs (NSAIDs) and citalopram. Case Summary: A 34-year-old white woman with a history of chronic thrombocytopenia (baseline platelet count 120–130 × 10 3 /μL) presented to the emergency department (ED) after noticing an increase in bruising on her upper and lower extremities. When the patient was interviewed, it was found that her dose of citalopram had been recently increased from 20 to 40 mg/day and she had started ibuprofen (dose unknown) on her own to manage rib pain approximately 1 month after the citalopram dosage increase. The patient was advised to discontinue ibuprofen and was discharged. Shortly thereafter, she was started on oxaprozin 600 mg twice daily for management of trochanteric bursitis. She returned to the ED stating that bruising occurred 1 week after she was given oxaprozin. At this visit, the patient was told to discontinue oxaprozin and naproxen 440 mg twice daily was prescribed. One week later, the patient again returned to the ED with complaints of spontaneous bruising. At this point citalopram and naproxen were discontinued and she was started on acetaminophen (dose not documented) and buspirone 10 mg twice daily. No other episodes of ecchymosis have occurred in the 8 months since this change to her drug regimen. Discussion: Medications that increase the risk of bleeding should be carefully administered in patients who have a low platelet count. This patient experienced bruising when her dose of citalopram was increased and an increase in bruising when she combined an NSAID with citalopram. Selective serotonin reuptake inhibitors (SSRIs) may increase antiplatelet activity of NSAIDs and could therefore increase the risk of bruising. Use of the Horn Drug Interaction Probability Scale indicated a possible interaction with concomitant use of NSAIDs and citalopram. Conclusions: Patients who experience NSAID- and/or SSRI-related bruising should consult their providers and alternative treatments should be considered.