Is lymphocytic colitis a known side effect of sertraline?/nA 62-year-old woman is treated with sert

Fråga: Is lymphocytic colitis a known side effect of sertraline? A 62-year-old woman is treated with sertraline 100 mg/d for depression. Shortly after starting the pharmacologic therapy, she developed diarrhoea and was subsequently diagnosed with lymphocytic colitis.

Sammanfattning: Sertraline exposure may be associated with an increased risk of lymphocytic colitis.

Svar: Lymphocytic colitis is included in a group of diagnoses collectively described as microscopic colitis. Microscopic colitis is characterised by histologic, but no endoscopic or radiological abnormalities and its primary symptom is persistent, non-bloody diarrhoea (1).

Although the pathogenesis of lymphocytic colitis remains uncertain, many reports have associated the onset with exposure to various drugs (2). Among those drugs, two review articles specifically mention sertraline, stating that there is a high probability of causal relationship between exposure to this drug and and the risk of developing lymphocytic colitis (1,2).

In a retrospective analysis of 199 Swedish patients with lymphocytic colitis, an association with drug exposure was suspected in 19 cases (10 percent). In seven of these cases, sertraline was the offending drug, with only one report of another antidepressant (paroxetine). In cases where the colitis was thought to be an adverse drug reaction, the onset of diarrhoea was between five days and four months after introduction of the drug. After withdrawal of the suspected drug, clinical improvement was seen in only three of the nineteen patients with drug-induced colitis, while the majority did not improve spontaneously (3).

In the Swedish adverse drug reactions register (Swedis), there are two reports of microscopic colitis with a possible association to sertraline exposure. In addition, there are 35 reports of diarrhoea, which may however be unrelated to colitis. There are only two additional reports of colitis in patients treated with selective serotonin reuptake inhibitors (SSRIs) other than sertraline. In both cases, paroxetin was the suspected culprit (4).

Finally, a case-control study in 233 individuals has investigated the association between SSRI exposure and the risk of developing microscopic colitis. Both collagenous and lymphocytic colitis was strongly associated with SSRI exposure, with odds ratios of 21 and 38, respectively. The majority of the SSRI-exposed patients with lymphocytic colitis had been using sertraline, while there was no such pattern in patients with collagenous colitis. Notably, the control group was recruited from an outpatient surgery unit (mainly cataract patients) and may not be fully comparable to the patients with colitis, although age and gender was controlled for in the analysis (5).

In the present case, it is possible that sertraline has elicited the lymphocytic colitis. We recommend withdrawal of the drug, although it is unclear to what extent this will improve the prognosis. We also recommend this case be reported to the regional adverse drug reaction monitoring centre.