Parenteral amino acid and serotonin syndrome

[WheezyBaby]

My hospital system has a high alert flag for parenteral AA's + serotonergic drugs, but I'm having a hard time finding any literature to substantiate it. Best I could find was a study protocol for an experimental amino acid that excluded patients on an SSRI. Was able to find a case report of NMS from parenteral AA's in a patient with Parkinsons which maybe offers some biological plausibility. Just wondering if this is a real thing or not

---

Members don't see this ad.

 

[Rockinacoustic]

Never seen this at my shop. Are these "real" serotonergic agents or things like fentanyl and ondansetron?

If the patients is sick enough to need PN then they are likely barely exceeding their normal RDI of AA so this sounds theoretical vs a true contraindication. And as long as they aren't paralyzed you can monitor for signs of SS/NMS.

 

[WheezyBaby]

Linezolid was the flag I recall. Def doesn't flag for Zofran or fentanyl. Don't know that I've had a TPN / SSRI yet. It didn't sound particularly plausible to me. Thanks!

 

[Dred Pirate]

oh my gosh, an actually pharmacy question!

I have never heard of this- I did make TPN's for 10 years (I haven't in several). From a clinical standpoint it just doesn't make sense. You injest AA's all the time whether or not you are on TPN. I guess if the AA has escessive amounts of tryptophan vs a normal diet, theoretically it could happen. I would be very surprised if actually would occur thou.

 

[sadface]

FWIW I have had patients on SSRI and TPN, haven’t heard of this interaction though.

 

[PharmDBro2017]

oh my gosh, an actually pharmacy question!

I have never heard of this- I did make TPN's for 10 years (I haven't in several). From a clinical standpoint it just doesn't make sense. You injest AA's all the time whether or not you are on TPN. I guess if the AA has escessive amounts of tryptophan vs a normal diet, theoretically it could happen. I would be very surprised if actually would occur thou.

Ironically enough my EMR flagged Zyvox + TPN today and when I read the report it said tryptophan and serotonin syndrome blah blah blah.

 

[BidingMyTime]

I agree with everyone else, this isn't a real concern. Your question was the first time I'd even heard it brought up as a concern. Auto-alerts are good overall, but man, some of the stuff they flag is just nonsensical. If its an alert you've never seen, it's worth investigating, but don't be surprised to learn its a nothingburger.

 

[Olivia D]

This type of syndrome? I had never heard about this, today don't know what type of real diseases or fake diseases we have to face.

 

[Dred Pirate]

This type of syndrome? I had never heard about this, today don't know what type of real diseases or fake diseases we have to face.

Not to be mean but are you a pharmacist and don’t know what serotonin syndrome is? SMH.

 

[mustang sally]

I have never heard of this (not that that necessarily means anything though).

 

[BidingMyTime]

How does a pharmacist not have a basic idea of what serotonin syndrome is? They syndrome itself isn't that uncommon, plus there are so many drug combos that can put someone at risk for it. Not knowing about it is as bad as the pharmacist who wrote a clinical article for Drug Topics a few years back advocating putting pregnant women on ACEI's. (In case you don't know, but you really should, ACEI are contraindicated in pregnant women. )

 

[WorthlessOxygen]

Not knowing about it is as bad as the pharmacist who wrote a clinical article for Drug Topics a few years back advocating putting pregnant women on ACEI's.

Wait really?

 

[Dred Pirate]

How does a pharmacist not have a basic idea of what serotonin syndrome is? They syndrome itself isn't that uncommon, plus there are so many drug combos that can put someone at risk for it. Not knowing about it is as bad as the pharmacist who wrote a clinical article for Drug Topics a few years back advocating putting pregnant women on ACEI's. (In case you don't know, but you really should, ACEI are contraindicated in pregnant women. )

I think it just goes to show the quality of the average pharmacist out there. I haven’t worked retail for a decade but if you read the interaction alerts, you are bound to run across it at some point. I mean, haven’t you filled ultramarine for a pt on an SSRI? (The most common SS alert I can think of at this time) I know I are it come up as a possibility likely on almost a daily basis.

 

[BidingMyTime]

Wait really?

Pharmacy Times Case Studies Question

So the latest Pharmacy Times has a case study concerning a woman who refuses vaccines due to religious beliefs, but wants a recommendation for prophylaxis treatment for meningitis. Interestingly, she is also on a BCP. The answer gives 3 choices, one of which is ceftriaxone, which Pharmacy Times...

forums.studentdoctor.net

Response #27 in the thread talks about the ACEI and pregnant woman.
It was actually Pharmacy Times and it was a Case Study.

Ah, the thread brought back memories of anger and ire at reading Pharmacy Times. I don't read Pharmacy Times anymore, even though I still get it for free. Since then I've discovered Twitter, and I can get much more anger and ire at the same low price of FREE. Although Twitter is much more of a time suck.....so there is that drawback.