Serotonin syndrome risk

[perromaxfilm]

I have seen many patients on combination SSRIs, Wellbutrin and SNRI, often prescribed by psych. I think using Tramadol PRN for breakthrough pain in combination with regular duloxetine use seems reasonable given the rarity of serotonin syndrome. Alternative opioids have their own set of risks that may be worse. Is anyone doing this? Thanks.

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[lobelsteve]

All the time.
Never seen it.
Can happen with multiple meds or even 25mg Paxil by itself.

 

[Sushirolls]

Psych here.

Tramadol is higher on my risk scale. Usually don't get too concerned until on med #5, but tramadol is of concern and I usually urge my patients to try to come off of it or not use it. Haven't looked at the literature of tramadol and SS since residency.

 

[DubVille]

Saw it once as an intern. Patient t was on max dose if tramadol (400mg a day) went to max dose of prozac or zoloft the week before.

Never seen otherwise. I will use it with cymbalta, but tell patients about it and wont go over 200mg on tram trams.

 

[Ducttape]

keep tramadol or Cymbalta a little lower. for example, 60 mg Cymbalta and 200 mg max tramadol.

age and underlying health factor greatly.

all the cases of serotonin syndrome I have seen have been in those >85. so if over 80, max dose is 40 mg Cymbalta and I use ultracet (37.5 mg/acetaminophen) max 6 pills daily

 

[BobBarker]

I typically don’t go over 100mg tramadol on someone taking cymbalta.

 

[clubdeac]

I saw it once in a vet prescribed Zoloft, Seroquel, tramadol, wellbutrin and imitrex by the VA. He was tremulous and hyper-reflexic with intermittent myoclonus. We tapered him down on several of the meds and it all resolved. They were extremely thanksful