serotonin syndrome and SSRIS

[quickfeet]

---

Members don't see this ad.

So far as I can tell, serotonin toxidrome is not associated with SSRI monotherapy, but on SSRIs in combination with a number of serotonergic agents. Correct?

 

[nitemagi]

For the most part, that's true. I did read a case report of serotonin syndrome that was lethal in someone that took a mega-overdose of Paxil XR...Where's that reference...There!
http://www.ncbi.nlm.nih.gov/pubmed/20833944

 

[quickfeet]

For the most part, that's true. I did read a case report of serotonin syndrome that was lethal in someone that took a mega-overdose of Paxil XR...Where's that reference...There!
http://www.ncbi.nlm.nih.gov/pubmed/20833944

Ahhh but we're (I guess by that I mean "you" since I'm just a med student) not seeing it with people who take prozac 20mg QD for their depression alone? It is restricted to overdose or combo with things such as amphetamines, MAOIs, triptans, certain antibiotics, etc.?

 

[nitemagi]

Ahhh but we're (I guess by that I mean "you" since I'm just a med student) not seeing it with people who take prozac 20mg QD for their depression alone? It is restricted to overdose or combo with things such as amphetamines, MAOIs, triptans, certain antibiotics, etc.?

I would say that's correct, yes. Have to present a question for rounds, eh? 😀

Here's a pretty good review article on SS.

 

[freaker]

Serotonin syndome is such a rare pheonomenom. Still, I always get a bit anxious when I have a patient maxing out an SSRI, getting relief from buspirone, and then they say they're not sleeping well.

How risk adverse are many of you to prescribing trazodone in the above setting? Especially in my patients with HTN and who are already overweight, I tend to shy away from mirtazapine. Same thing with atypicals and the host of other side-effects and expenses. I tend to not like sedatives in the first place, and many have adverse side-effects from them (e.g. sleep walking).

 

[billypilgrim37]

Serotonin syndome is such a rare pheonomenom.

Severe serotonin syndrome is fairly rare. Milder forms are pretty common.

 

[splik]

you wouldn't expect serotonin syndrome with monotherapy within the therapeutic range however it definitely occurs in overdose with SSRIs but is much more common with SSRI + SSRI, SSRI + MDMA, SSRI + MAOI, SSRI + Tramadol/Demerol etc. I am quite happy prescribing SSRI + mirtazapine and of course venlafaxine + mirtazapine was touted as 'california rocket fuel' by stahl etc.

It is not uncommon especially presenting with tremors, myoclonus, uncontrollable movements but the more serious or fatal serotonin syndrome is rare these days as there is a lot of awareness. Pharmacogenetics has elucidated it is more common in those who have certain CYP 2D6 polymorphisms and are thus poor metabolisers of SSRIs. The minor forms just require supportive treatment no need for cyproheptadine in the majority of cases. I believe dantrolene has fallen out of favor for serotonin syndrome now?

 

[nitemagi]

you wouldn't expect serotonin syndrome with monotherapy within the therapeutic range however it definitely occurs in overdose with SSRIs but is much more common with SSRI + SSRI, SSRI + MDMA, SSRI + MAOI, SSRI + Tramadol/Demerol etc. I am quite happy prescribing SSRI + mirtazapine and of course venlafaxine + mirtazapine was touted as 'california rocket fuel' by stahl etc.

It is not uncommon especially presenting with tremors, myoclonus, uncontrollable movements but the more serious or fatal serotonin syndrome is rare these days as there is a lot of awareness. Pharmacogenetics has elucidated it is more common in those who have certain CYP 2D6 polymorphisms and are thus poor metabolisers of SSRIs. The minor forms just require supportive treatment no need for cyproheptadine in the majority of cases. I believe dantrolene has fallen out of favor for serotonin syndrome now?

Conservative treatment is best, cyproheptadine is an option, but want to be careful as it's antihistamine/anticholinergic adds a risk of anticholinergic delirium or cardiac problems if using too much. We had a thread on this a while back. There's also some data on using other sedatives such as propofol temporarily as well as 5HT-2A antagonists as options for treatment, mostly by case reports. Some theorize it's specific receptor subtypes responsible for SS, though I'm not sure the data is conclusive.
http://www.nejm.org/doi/full/10.1056/NEJM200506093522320

 

[whopper]

I've only seen serotonin syndrome occur in about 3 patients. In those patients, their SSRIs were raised faster than the manufacturer's recommendation, and this was only done because the attending the resident was working under at the time was totally 100% against benzo use and the patients had severe anxiety. The resident, in an attempt to overcompensate, raised the SSRI faster than usual.

I'm generally 90% against benzo use. I do allow for it under certain circumstances such as temporary treatment for only a few weeks tops, then it usually must stop or to treat anticipatory anxiety where the patient only takes it about once every few days or less. Raising an SSRI faster than it should is not worth it given that the benefits won't be had for weeks anyway.

 

[cbrons]

I've only seen serotonin syndrome occur in about 3 patients. In those patients, their SSRIs were raised faster than the manufacturer's recommendation, and this was only done because the attending the resident was working under at the time was totally 100% against benzo use and the patients had severe anxiety. The resident, in an attempt to overcompensate, raised the SSRI faster than usual.

I'm generally 90% against benzo use. I do allow for it under certain circumstances such as temporary treatment for only a few weeks tops, then it usually must stop or to treat anticipatory anxiety where the patient only takes it about once every few days or less. Raising an SSRI faster than it should is not worth it given that the benefits won't be had for weeks anyway.

Are psychiatrists generally only prescribing the longer-acting benzos (diazepam, clonazepam) for 3-4 weeks max? I see many more long-term benzo users on ativan or xanax coming only from GPs.

 

[whopper]

IMHO, psychiatrists are better trained in the potential problems that can occur with benzos, but unfortunately I too see too many psychiatrists giving it out too much. One psychiatrist I know of gives any patient and drug of abuse they want with no warning of the potential addiction and dependence that could develop. E.g. and I'm not making this up, a guy with paranoid personality disorder on Concerta, a patient on Restoril 60 mg QHS (twice the max dosage and she's underweight), and a patient on Adderall because the doctor told the patient that she's attractive but would be more so if she lost weight and Adderall could help with that.

One phenomenon in the long term units is several psychiatrists order Haldol 5 mg Q6 hrs PRN, cogentin 1 mg Q6 hrs PRN for EPS, and Ativan Q6 hrs PRN for agitation, but the nurse can give all three or just one or two of them.

What ends up happening is a lot of the drug abusing patients say they are agitated, even using the literal word, the nurse not wanting to deal with the patient gives them ativan, and then it turns out they get several mg a day.

The psychiatrist, not checking up on how much was actually given per day doesn't know why the guy doesn't want to be discharged, and whenever he is, does everything to get back to the unit. My policy is on my forensic unit that no nurse is allowed to give out Ativan only unless they ask me first, otherwise it only goes into a cocktail of an antipsychotic with it, mind you I hardly ever get any anxiety DO patients on my forensic unit.

 

[BobA]

Are psychiatrists generally only prescribing the longer-acting benzos (diazepam, clonazepam) for 3-4 weeks max? I see many more long-term benzo users on ativan or xanax coming only from GPs.

Benzo's only get you so far because of the tolerance. There's not much point to long term use.

Moreover, they can interfere with psychotherapy (esp CBT), which is first-line treatment for anxiety.

I will use benzo's in BPAD, or Schizo-spectrum disorders.

Otherwise, I rarely start benzo's and always try to taper people who come to me on benzo's. Of course, the taper often is unsuccessful and so I'll then continue them in a reliable patient.

 

[Ceke2002]

Bumping an old thread to add a personal experience that might be of help in determining risk factors for Serotonin Syndrome with SNRI's in conjunct with a serotonergic agent.

I developed a certain degree of Serotonin Syndrome on a combination of 300mgs daily of Tramadol & 75mgs of Effexor. These are the specific symptoms I experienced:

Manic euphoria, that very quickly progressed into extreme agitation, muscle tremors and rigidity, uncontrollable body jerks, jaw tension, teeth grinding and clenching, and strobe vision.

At the ED it was discovered that my blood pressure was basically through the roof (220/151 was the second reading and the treating Doctor actually expressed relief that it had dropped at that point). A nurse was immediately assigned to my bedside, with strict instructions not to move (I'm not entirely sure why, maybe they thought I was going to stroke out or have a heart attack, or something, because of my blood pressure readings 😕) then they put me on a drip, and gave me what felt like some sort of calmative or muscle relaxant. I spent close to over 16 hours in the Emergency Department, until they'd stabilised my blood pressure, and I was no longer a) manic and b) showing physical symptoms.

Anyway I know this is coming from a lay person, and is only anecdotal, but I hope it helps with identifying potential risk factors for any patients who might be on a combination of the same meds. As I understand it I did experience a mild to moderate degree of Serotonin Syndrome, nonetheless it's not an experience I wish to repeat in a hurry, and I certainly wouldn't wish it on anyone else.