Quetiapine (NMS) and Citalopram (Serotonin Syndrome)

learn how to start a private practice
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
J

jojo420

Full Member
15+ Year Member
Joined
Jul 21, 2009
Messages
117
Reaction score
8
Members don't see this ad.
A man comes to the ED with muscle rigidity, tremor, febrile, tachycardic, and has fluctuating blood pressure. The question asks which medication he could be on. What is your opinion of the most likely medication?.

Quetiapine or Citalopram?

Which is a more likely answer?
 
Even though I shouldn't be doing your homework for you, I'm pretty sure they're referring to NMS here, so it wouid be the quetiapine. If they were suggesting serotonin syndrome, he'd have myoclonus and wouldn't necessarily be so rigid. That's my take, anyhow.
 
One source i found says this about serotonin syndrome:

. The clinical picture can range from mild agitation, tremor, and gastrointestinal (GI) symptoms in less severe cases, to a state of extreme muscle rigidity with hyperthermia that demands immediate intervention.4

As I understand, NMS is extremely rare with atypical antipsychotics. Would serotonin syndrome be more common with a single drug intake of citalopram?
 
Rigidity vs hyperkinesis is one of the "textbook" ways of differentiating NMS from SS. SS has hyperactive reflexes and clonus, NMS rigidity. It's not always that clear in real life, but including the rigidity here suggests they are going for NMS. Plus, SS on a single serotonergic agent would be weird. But I've seen NMS on clozapine. Crazy stuff happens. Quetiapine seems like the "better" answer.
 
NMS is almost unheard of with quietapine, so without hearing more of the question, it's very difficult to tell. If this was SS, it could be either med, though we don't know the dosages of each. If it's NMS, based on the 2 choices it'd have to be quietapine (though if another antipsychotic were there, it'd more likely be that one vs. quietapine).

The reason being that NMS is more likely with more D2 blockage and quietapine is one of the weakest D2 blockers out there vs other antipsychotics. I was at a lecture showing the numbers of NMS occurrences and the meds the patient was on and quietapine, as expected was on the bottom or close to the bottom vs the other antipsychotics.
 
whopper said:
The reason being that NMS is more likely with more D2 blockage and quietapine is one of the weakest D2 blockers out there vs other antipsychotics. I was at a lecture showing the numbers of NMS occurrences and the meds the patient was on and quietapine, as expected was on the bottom or close to the bottom vs the other antipsychotics.
Click to expand...

While true, I bet the 85-pound 6-foot-tall woman with anorexia and chronic renal disease I admitted last week on 1500mg/day of Seroquel could manage a quite impressive, fatal NMS.
 
I'm wondering just what caused a prescriber to give out 1500 mg a day of quetapine to anyone, let alone a very low weight person.

It's either an extreme case where there were few options or the prescriber didn't know what they were doing or something in-between.

At the state facility where I used to work at, we had several treatment resistant and incredibly violent due to psychosis or mania cases and Clozaril use was common. The facility had state-backed guidelines on prescribing meds that were above the prescriber's recommended guidelines, based on extensive review of the literature (e.g. Zyprexa at 40 mg a day, Depakote at serum level of 150 ug/ml), but none of them ever allowed anyone to do Seroquel at 1500 mg.
 
whopper said:
I'm wondering just what caused a prescriber to give out 1500 mg a day of quetapine to anyone, let alone a very low weight person.

It's either an extreme case where there were few options or the prescriber didn't know what they were doing or something in-between.

At the state facility where I used to work at, we had several treatment resistant and incredibly violent due to psychosis or mania cases and Clozaril use was common. The facility had state-backed guidelines on prescribing meds that were above the prescriber's recommended guidelines, based on extensive review of the literature (e.g. Zyprexa at 40 mg a day, Depakote at serum level of 150 ug/ml), but none of them ever allowed anyone to do Seroquel at 1500 mg.
Click to expand...

Believe me, that wasn't even the most horrendous part of her medication regimen. The fact that her EKG was relatively benign (despite the bradycardia and the K of 2.4) was also a shocker. I was disappointed that the pharmacy didn't call me about the order.

My only thought is that perhaps with someone with anorexia that the patient is so hypoalbuminemic that maybe the serum level wouldn't correlate with something so incredibly high? Given that she wasn't having EPS, wasn't sedated, didn't have QTc prolongation, etc., that seems possible. I also wonder what that degree of anorexia does to the p450 system. All pure speculation and conjecture, of course.

While I don't know who started the regimen, the psychiatrist who continued it during the previous hospitalization is an eating disorder specialist and a very good, thoughtful psychiatrist. But as I said, I'm equally perplexed by the whole ordeal.
 
whopper said:
At the state facility where I used to work at, we had several treatment resistant and incredibly violent due to psychosis or mania cases and Clozaril use was common. The facility had state-backed guidelines on prescribing meds that were above the prescriber's recommended guidelines, based on extensive review of the literature (e.g. Zyprexa at 40 mg a day, Depakote at serum level of 150 ug/ml), but none of them ever allowed anyone to do Seroquel at 1500 mg.
Click to expand...

Btw, did you wind up with a lot of patients on 575mg of clozaril? Given literature that the risk of seizures goes up at 600mg, I've seen an inordinate number of people on 575mg (usually people who had a history of seizure on it before). I didn't know if this was just specific to my locale or if anybody else saw this.
 
jojo420 said:
A man comes to the ED with muscle rigidity, tremor, febrile, tachycardic, and has fluctuating blood pressure. The question asks which medication he could be on. What is your opinion of the most likely medication?.

Quetiapine or Citalopram?

Which is a more likely answer?
Click to expand...

I would choose celexa for the following reasons:

No mention was made of his mental status exam, or of him being altered. It's more likely that someone would be cognitively intact with SS than NMS. Additionally, a lesser clue is mentioning tachycardia specifically, which is more specific for SS
 
Given literature that the risk of seizures goes up at 600mg, I've seen an inordinate number of people on 575mg (usually people who had a history of seizure on it before). I didn't know if this was just specific to my locale or if anybody else saw this.
Click to expand...

In my area, several providers start Depakote somewhere at a Clozaril dosage of 400-500 mg because of the seizure problem and if someone is so psychotic needing Clozarl, the Depakote may help.

This is something I didn't know of at all in residency, and Clozaril patients were extremely rare in the clinical settings there.

From what I've been told, Paul Keck made a push for psychiatrists in this local area to be mindful of the seizure risk and made it the standard in this area.

As for the eating disorder patient, I did a rotation under Russell Marx, a leading ED psychiatrist and while I haven't told him about the above case, I'd hardly think he'd approve Seroquel at 1500 mg a day, especially since he told me that he never could recommend any specific meds to be highly effective in any eating disorder. So to give such a high dose to someone that this this description--wow. That'd certainly be an interesting case to investigate.

I could see even a good doctor doing the above if the circumstances were that dire or extreme, but this is a type of thing that I'd only expect to see every few years.
 
Last edited:
vistaril said:
I would choose celexa for the following reasons:

No mention was made of his mental status exam, or of him being altered. It's more likely that someone would be cognitively intact with SS than NMS. Additionally, a lesser clue is mentioning tachycardia specifically, which is more specific for SS
Click to expand...

If this is a board review type of question, the SS patient will have myoclonic jerks or at least induceable clonus on exam. That is one of the few distinguishing factors.
 
xlithiumx said:
If this is a board review type of question, the SS patient will have myoclonic jerks or at least induceable clonus on exam. That is one of the few distinguishing factors.
Click to expand...

don't neccessarily disagree, but most board questions with NMS will comment in some way on mental status as well. And as someone else mentioned, seroquel is not a typical AS to use for an NMS example.
 
I would go with Quetiapine but it is not the best question.

As far as taking 1500mg of Seroquel. The recommended daily max is around 800mg. I have seen up to 1200mg and I advised to back off.

I know sometimes in Psy you have to do what you have to do to get the patient better but I think there are better combinations than dosing Seroquel that high.
 
Seroquel

On boards they are trying to get you to distinguish between rigidity in NMS and myoclonus in SS. With that said, this is a horrible question as was said it would be odd to get NMS with seroquel specifically. They should have at least used another atypical. It would also be odd to get SS with just one SSRI and no other agents on board. As for mental status, without a doubt it is more frequently altered in NMS, but personally if the the question dosen't mention it at all it's not normal or abnormal. To me you just disregard the fact that either has an effect on mental status unless the quesiton specifically comments on it.
 
You must log in or register to reply here.

Similar threads

the5thelement
Lamotrigine and Steven Johnsons syndrome
Replies
17
Views
2K
doctalaughs
D
Sushirolls
Chronic Fatigue Syndrome
Replies
30
Views
3K
clozareal
clozareal
Merovinge
Quetiapine XR vs IR
Replies
9
Views
3K
Merovinge
Merovinge
pisekar
DiGeorge Syndrome and metirosine
Replies
5
Views
650
deleted1100659
D
M
signaling and dual applying
Replies
21
Views
1K
TexasPhysician
TexasPhysician
Top