Drug General Information (ID: DDIYGRDNK1)
Drug Name			Ticlopidine		Drug Info		Escitalopram		Drug Info
Drug Type		Small molecule				Small molecule
Therapeutic Class		Fibrinolytic Agents				Antidepressants
Structure

Mechanism of Ticlopidine-Escitalopram Interaction (Severity Level: Moderate)
Increased risk of bleeding Click to Show/Hide Mechanism Graph
Drug Name		Ticlopidine				Escitalopram
Mechanism 1		Risk of bleeding Antiplatelet				Risk of bleeding Antiplatelet effects
Key Mechanism Factor 1
		Factor Name		Bleeding
		Factor Description		Patients may be at risk for bleeding when the outcome of a disease or disease treatment confounds the standard mechanisms for maintaining hemostasis. Signs or symptoms of abnormal bleeding include: bleeding that takes a long time to stop (including nosebleeds, bleeding gums, bleeding from cuts and abrasions, and menstrual bleeding); severe unexplained bruising, or bruising that becomes larger; blood in the urine or stool, etc.
Mechanism Description		Increased risk of bleeding by the combination of Ticlopidine and Escitalopram
Mechanism 2		Risk of bleeding Antiplatelet				Risk of bleeding Antiplatelet effects
Key Mechanism Factor 2
		Factor Name		Bleeding
		Factor Description		Patients may be at risk for bleeding when the outcome of a disease or disease treatment confounds the standard mechanisms for maintaining hemostasis. Signs or symptoms of abnormal bleeding include: bleeding that takes a long time to stop (including nosebleeds, bleeding gums, bleeding from cuts and abrasions, and menstrual bleeding); severe unexplained bruising, or bruising that becomes larger; blood in the urine or stool, etc.
Mechanism Description		Increased risk of bleeding by the combination of Ticlopidine and Escitalopram

Recommended Action
Management		Caution is advised if escitalopram must be used in combination with CYP450 2C19 inhibitors including ticlopidine. Pharmacologic response to escitalopram should be monitored more closely whenever ticlopidine is added to or withdrawn from therapy, and the escitalopram dosage adjusted as necessary. This may be particularly important in patients receiving escitalopram at the upper end of the dosage range. Patients should be advised to seek medical attention if they experience symptoms that could indicate the occurrence of torsade de pointes such as dizziness, lightheadedness, fainting, palpitation, irregular heartbeat, shortness of breath, or syncope. Patients should also be closely monitored for symptoms of the serotonin syndrome and potential bleeding complications during treatment.

References
1	Alderman CP, Seshadri P, Ben-Tovim DI "Effects of serotonin reuptake inhibitors on hemostasis." Ann Pharmacother 30 (1996): 1232-4. [PMID: 8913401]
2	Canadian Pharmacists Association.
3	Cerner Multum, Inc. "Australian Product Information.".
4	Cerner Multum, Inc. "UK Summary of Product Characteristics.".
5	Chan BSH, Graudins A, Whyte IM, Dawson AH, Braitberg G, Duggin GG "Serotonin syndrome resulting from drug interactions." Med J Aust 169 (1998): 523-5. [PMID: 9861909]
6	Corkeron MA "Serotonin syndrome - a potentially fatal complication of antidepressant therapy." Med J Aust 163 (1995): 481-2. [PMID: 7476638]
7	Dalton SO, Johansen C, Mellemkjaer L, Norgard B, Sorensen HT, Olsen JH "Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study." Arch Intern Med 163 (2003): 59-64. [PMID: 12523917]
8	de Abajo FJ, Jick H, Derby L, Jick S, Schmitz S "Intracranial haemorrhage and use of selective serotonin reuptake inhibitors." Br J Clin Pharmacol 50 (2000): 43-7. [PMID: 10886117]
9	de Abajo FJ, Rodriguez LA, Montero D "Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study." BMJ 319 (1999): 1106-9. [PMID: 10531103]
10	Insel TR, Roy BF, Cohen RM, Murphy DL "Possible development of the serotonin syndrome in man." Am J Psychiatry 139 (1982): 954-5. [PMID: 7091416]
11	Laird LK "Issues in the monopharmacotherapy and polypharmacotherapy of obsessive-compulsive disorder." Psychopharmacol Bull 32 (1996): 569-78. [PMID: 8993077]
12	Lane R, Baldwin D "Selective serotonin reuptake inhibitor--induced serotonin syndrome: review." J Clin Psychopharmacol 17 (1997): 208-21. [PMID: 9169967]
13	Martin TG "Serotonin syndrome." Ann Emerg Med 28 (1996): 520-6. [PMID: 8909274]
14	Mills KC "Serotonin syndrome: A clinical update." Crit Care Clin 13 (1997): 763. [PMID: 9330840]
15	Nierenberg DW, Semprebon M "The central nervous system serotonin syndrome." Clin Pharmacol Ther 53 (1993): 84-8. [PMID: 8257462]
16	Nijhawan PK, Katz G, Winter S "Psychiatric illness and the serotonin syndrome: an emerging adverse drug effect leading to intensive care unit admission." Crit Care Med 24 (1996): 1086-9. [PMID: 8681579]
17	Product Information. Lexapro (escitalopram). Forest Pharmaceuticals, St. Louis, MO.
18	Settle EC "Antidepressant drugs: disturbing and potentially dangerous adverse effects." J Clin Psychiatry 59 Suppl 16 (1998): 25-30. [PMID: 9796863]
19	Skop BP, Brown TM "Potential vascular and bleeding complications of treatment with selective serotonin reuptake inhibitors." Psychosomatics 37 (1996): 12-6. [PMID: 8600488]
20	Sternbach H "The serotonin syndrome." Am J Psychiatry 148 (1991): 705-13. [PMID: 2035713]
21	Layton D, Clark DWJ, Pearce GL, Shakir SAW "Is there an association between selective serotonin reuptake inhibitors and risk of abnormal bleeding? Results from a cohort study based on prescription event monitoring in England." Eur J Clin Pharmacol 57 (2001): 167-76. [PMID: 11417450]