neuroleptic malignant syndrome vs serotonin syndrome

[uclacrewdude]

quick question that wasnt available using the search engine (regarding step 2). can anyone give me a quick and easy way to differentiate 5HT syndrome vs NMS? i know they arise from different medications, but all the vignettes i get from qbank have pts that are bat**** crazy and arent using antipsychotics or serotonergic drugs (eg a bipolar pt). what now?

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[TheCat]

Most of the symptoms are pretty much the same or indistuingashable however on lab values-NMS will have elevated muscle breakdown so increased levels of CKand also will have elevated liver enzymes-neither of which are found in SS

 

[omarsaleh66]

I think serotonin syndrome is related to mixing SSRIs and MAOIs. I forgot the symptoms but i think its flu-like Sx. Anything that gives u excessive serotonin.

NMS is a reaction from an antipsychotic like haldol. Fever, Muscular rigidity, CK levels increase. Treat w dantrolene or benztropine.

 

[TheCat]

I think serotonin syndrome is related to mixing SSRIs and MAOIs. I forgot the symptoms but i think its flu-like Sx. Anything that gives u excessive serotonin.

NMS is a reaction from an antipsychotic like haldol. Fever, Muscular rigidity, CK levels increase. Treat w dantrolene or benztropine.

obviously serotonin syndrome is frome excess sertotonin and NMS is obviously from antipyschotics-the original poster was not asking what they were-he was commenting on how similar they are symptom wise and how to differentiate them-and actually anticholinergics like benztropine is the exact opposite of what you want to do and is NOT the treatment-NMS is due to a developing hypersensitivity of dopamine receptors caused by long term blockage of the receptors by D-antagonists-which leads to extreme upregulation over time which causes a supersensitivity to any remaining dopamine-which ends up outweighing the blocking effects of the antipyschotic the person is on-so basically you have too much dopamine stimulation-and dopamine inhibits GABA receptors in the brain so you have excitatory overload- Cholinergic neurons in the same areas cause stimulation of GABA which causes supresion-so giving anticholinergics make things worse by decreasing GABA further and even more stimulating the excitatory pathways responsible for NMS-if anything you increase the antipyschotic in the ST to relieve symptoms as well as the dantrolene to prevent muscle necrosis-then you try to stop the antipyschotic completely or switch to clozaril which isknown to have the least chance of NMS- so anyway that is how you treat.

 

[omarsaleh66]

obviously serotonin syndrome is frome excess sertotonin and NMS is obviously from antipyschotics-the original poster was not asking what they were-he was commenting on how similar they are symptom wise and how to differentiate them-and actually anticholinergics like benztropine is the exact opposite of what you want to do and is NOT the treatment-NMS is due to a developing hypersensitivity of dopamine receptors caused by long term blockage of the receptors by D-antagonists-which leads to extreme upregulation over time which causes a supersensitivity to any remaining dopamine-which ends up outweighing the blocking effects of the antipyschotic the person is on-so basically you have too much dopamine stimulation-and dopamine inhibits GABA receptors in the brain so you have excitatory overload- Cholinergic neurons in the same areas cause stimulation of GABA which causes supresion-so giving anticholinergics make things worse by decreasing GABA further and even more stimulating the excitatory pathways responsible for NMS-if anything you increase the antipyschotic in the ST to relieve symptoms as well as the dantrolene to prevent muscle necrosis-then you try to stop the antipyschotic completely or switch to clozaril which isknown to have the least chance of NMS- so anyway that is how you treat.

Thanks for pointing out that mistake.
my bad, i meant bromocriptine, not benztropine.

anyway, main way to differentiate the 2, serotonin syndrome can present as a flu-like or viral illness could go unrecognized until its life threatening. It usually seen w serotinin meds, if u mix like SSRI w MAOI (obviously)

On a question, Serotonin syndrome can look like NMS but u wont see muscle rigidity or high fevers in serotonin syndrome like u would in NMS.

1

 

[TheCat]

Thanks for pointing out that mistake.
my bad, i meant bromocriptine, not benztropine.

anyway, main way to differentiate the 2, serotonin syndrome can present as a flu-like or viral illness could go unrecognized until its life threatening. It usually seen w serotinin meds, if u mix like SSRI w MAOI (obviously)

On a question, Serotonin syndrome can look like NMS but u wont see muscle rigidity or high fevers in serotonin syndrome like u would in NMS.

1

actually bromocriptine would worsen the problem-the whole problems is you are hypersensitive to dopamine due to upregulation of receptors that are overpowering the block of dopamine from your antipyschotics-so a dop agonsits would just cause more dopamine stimulation and excitment of the brain. yOU have to give more ANTI-dopamine meds-again dopamine agonists or anti cholinergics have the same net effects-increasing stimulation-review your basal ganglia chapter if needed

 

[omarsaleh66]

the mechanisms u are talking about sound like tardive dyskenisa. I may be totally wrong here and look really stupid, but I think I have to disagree. But maybe u can set this straight. The links below say that u would stop the antipsychotic and the NMS is 2^ to idiosyncratic rxn:


http://www.emedicine.com/emerg/topic339.htm

http://www.cmdg.org/Movement_/drug/Neuroleptic_Malignant_Syndrome/neuroleptic_malignant_syndrome.htm


later

 

[Anasazi23]

Don't ever increase the antipsychotic during NMS. Immediately stop the antipsychotic, and use supportive medical therapy...cooling blankets for fever, IV fluids, dantrolene if necessary.

Here's a little link that outlines the differences.

Here's a blurb from Max Fink on NMS, a psychiatrist who was very active in ECT.