Major
Acetylsalicylic acid × Fluoxetine
Antiplatelet agents (low dose) / NSAIDs (analgesic dose)×Selective serotonin reuptake inhibitors
Mechanism
Fluoxetine (SSRI) depletes the platelet serotonin pool, impairing primary haemostasis. Aspirin irreversibly blocks platelet cyclooxygenase. Combined, GI bleeding risk roughly doubles.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, black stools, blood in urine. Severe cases include gastrointestinal or intracranial haemorrhage.
Management
The combination is acceptable at low aspirin doses (75–100 mg as cardioprotection). PPI cover with pantoprazole is mandatory. Alternative antidepressants with minimal platelet effect: mirtazapine or agomelatine.