Moderate
Acetylsalicylic acid × duloxetine
Antiplatelet agents (low dose) / NSAIDs (analgesic dose)×SNRI
Mechanism
Duloxetine (SNRI) depletes the platelet serotonin pool, impairing primary haemostasis. Additively with aspirin's antiplatelet effect: GI bleeding risk roughly doubles.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, black or tarry stools. Severe cases: GI bleeding.
Management
The combination is acceptable at low aspirin doses (75–100 mg). PPI cover with pantoprazole is mandatory. Alternative antidepressants with minimal platelet effect: mirtazapine or agomelatine.