SSRI/SNRI Cross-Taper, increased risk for serotonin syndrome?

[Blitz2006]

Just wondering, because I came across some discussions on patients that were on Cymbalta/Effexor, and due to no efficacy, was decided to be switched to a SSRI. Also pain docs who want to switch a patient off SNRI...

But as we know, at higher doses of Effexor (>100 mg), less serotonin reuptake, and more on the Norepi reuptake.

So if you do a cross-taper, e.g, tapering at 225 mg Effexor, starting 20 mg Prozac, is there a heightened risk of serotonin syndrome? Should you first taper off the SNRI before starting the SSRI, or is that too conservative?

Can you get serotonin syndrome from re-uptaking Serotonin AND norepinephrine, or is it just serotonin (yes, I know, stupid question!)

Thanks,

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[st2205]

Too conservative. People tend to handle multiple serotonergic agents fairly decently (certainly not advocating that, just observing), that I'm not really worried about two agents or a temporary cross taper. I think, for however common SS is, that it's overcalled because medicine's internal conflict and anxiety with accepting or realizing there are some things we don't know or don't have an answer to/for. Most any time I've seen a primary team considering SS, it's a huge stretch when they're distressed and can't think of/find anything else. But I digress.

With Effexor, the much more real problem you're going to have is withdrawal syndrome, and starting that other SSRI/SNRI would be more important. Plus the psychological stress and anxiety a patient experiences when they believe "the treatment is being reduced and my depression/anxiety/marriage/self-esteem/suicidal thoughts/anger/whatever is going to go through the roof if I don't get something else on board!!!"

 

[Blitz2006]

Too conservative. People tend to handle multiple serotonergic agents fairly decently (certainly not advocating that, just observing), that I'm not really worried about two agents or a temporary cross taper. I think, for however common SS is, that it's overcalled because medicine's internal conflict and anxiety with accepting or realizing there are some things we don't know or don't have an answer to/for. Most any time I've seen a primary team considering SS, it's a huge stretch when they're distressed and can't think of/find anything else. But I digress.

With Effexor, the much more real problem you're going to have is withdrawal syndrome, and starting that other SSRI/SNRI would be more important. Plus the psychological stress and anxiety a patient experiences when they believe "the treatment is being reduced and my depression/anxiety/marriage/self-esteem/suicidal thoughts/anger/whatever is going to go through the roof if I don't get something else on board!!!"

Thanks!

But surely you don't recommend SSRI + SNRI for maintenance depression treatment, correct?

I tend to use STAR-D algorithm when I treat patients for MDD...

 

[st2205]

Thanks!

But surely you don't recommend SSRI + SNRI for maintenance depression treatment, correct?

I tend to use STAR-D algorithm when I treat patients for MDD...

No. I once had an attending (worst attending I've ever had, BTW), debate (ok, debate is being generous) with me about whether or not an SSRI + SNRI was "California rocket fuel." Also the same guy who believed if there wasn't an FDA indication for something, then it doesn't work (and the patient is lying [i.e. hydroxyzone for sleep]). Again I digress but there were so many stupid things in residency.

 

[HarryMTieboutMD]

Serotonin syndrome is RARE and yes, by definition it is the result of taking a serotonergic medication. I've seen it exactly once, and the patient had clonus, agitation, diaphoresis, etc. But the number of times I've seen it "diagnosed" inappropriately is quite large. Again you still have to take a history, do an exam, and think of a differential (you know, like doctors are supposed to do).

That said, aside from MAOIs (switching either way) you do not need to completely taper off ANY antidepressant before starting another one. I typically do 3 day cross tapers depending on the dose. Also, why are you going from SNRI to SSRI? If the patient's depression isn't getting better you need to think about TCAs/MAOIs or if really severe ECT

 

[Ceke2002]

Just wondering, because I came across some discussions on patients that were on Cymbalta/Effexor, and due to no efficacy, was decided to be switched to a SSRI. Also pain docs who want to switch a patient off SNRI...

But as we know, at higher doses of Effexor (>100 mg), less serotonin reuptake, and more on the Norepi reuptake.

So if you do a cross-taper, e.g, tapering at 225 mg Effexor, starting 20 mg Prozac, is there a heightened risk of serotonin syndrome? Should you first taper off the SNRI before starting the SSRI, or is that too conservative?

Can you get serotonin syndrome from re-uptaking Serotonin AND norepinephrine, or is it just serotonin (yes, I know, stupid question!)

Thanks,

I can't answer your specific question, but if it helps I've taken two different serotenergic (sp?) medications at once a number of times over the past 15 years, and I've only ever experienced a bonafide case of serotonin syndrome once in all of that time. Like HarryMTie said, it's rare.

 

[Shikima]

Serotonin syndrome is RARE and yes, by definition it is the result of taking a serotonergic medication. I've seen it exactly once, and the patient had clonus, agitation, diaphoresis, etc. But the number of times I've seen it "diagnosed" inappropriately is quite large. Again you still have to take a history, do an exam, and think of a differential (you know, like doctors are supposed to do).

That said, aside from MAOIs (switching either way) you do not need to completely taper off ANY antidepressant before starting another one. I typically do 3 day cross tapers depending on the dose. Also, why are you going from SNRI to SSRI? If the patient's depression isn't getting better you need to think about TCAs/MAOIs or if really severe ECT

Problem is that many will not get ECT. So I'm often combining SSRI+SNRI+TCA+SGA sometimes.
And good god, anxiety. People expecting you to make it go away - good lord.

 

[st2205]

Problem is that many will not get ECT. So I'm often combining SSRI+SNRI+TCA+SGA sometimes.
And good god, anxiety. People expecting you to make it go away - good lord.

"How's your medication working?"

"I don't think it's working too good. I've been under so much stress. My daughter told me I can't see her kids anymore. My anxiety is off the charts!"

 

[nexus73]

Remember that serotonin syndrome can have a broad range from mild to severe symptoms. In the example you give, it's possible the combo SSRI+SNRI might lead to some mild clonus (or other mild symptoms), but most psychiatrists aren't checking for this because it's clinically insignificant. It's extremely unlikely the cross taper will lead to severe symptoms.

It is worthwhile to keep in mind that using serotonergic medications in combination (eg Prozac+Buspar+Seroquel), can lead to mild serotonin syndrome symptoms without the severe presentation seen in the ICU/med floor.

Serotonin syndrome is much more common when medications are given in combo that inhibit metabolism of the serotonergic agent. For example, a patient on Prozac and recently started on Wellbutrin who is suicidal and overdoses on both. The high load of SSRI from Prozac overdose may cause serotonin syndrome on its own, but this is further exacerbated when Wellbutrin inhibits the 2D6 metabolism leading to a significant increased concentration of Prozac in the body.

 

[Ceke2002]

Remember that serotonin syndrome can have a broad range from mild to severe symptoms. In the example you give, it's possible the combo SSRI+SNRI might lead to some mild clonus (or other mild symptoms), but most psychiatrists aren't checking for this because it's clinically insignificant. It's extremely unlikely the cross taper will lead to severe symptoms.

Yep, this. Also keep in mind that some patients will either misinterpret symptoms of anxiety as serotonin syndrome, or experience somatised symptoms, or just present with an obviously factitious type presentation. I'm not going to link to it, but there's a video someone's put up on YouTube talking about their 'serotonin syndrome journey' and considering they have perfectly applied makeup, the camera angle is positioned at MySpace level, and the only symptoms they appear to be showing is a really put on sounding half stammer/half word panting, I'm calling BS.

Obviously serotonin syndrome does occur (hello, been there, done that, got the er wristband etc etc), but if I were a Doctor whose patient was claiming non emergent, vague type symptoms of serotonin syndrome I think I'd be looking pretty closely at a number of differential diagnoses.

 

[VA Hopeful Dr]

"How's your medication working?"

"I don't think it's working too good. I've been under so much stress. My daughter told me I can't see her kids anymore. My anxiety is off the charts!"

That kills me. Apparently we now have to medicate for any life stress a patient has

 

[st2205]

That kills me. Apparently we now have to medicate for any life stress a patient has

The worst part is that after you have that exact conversation with the patient, they say "so then what are we gonna do about my anxiety?"

 

[VA Hopeful Dr]

The worst part is that after you have that exact conversation with the patient, they say "so then what are we gonna do about my anxiety?"

Vistaril for everyone!

 

[Shikima]

And residency doesn't prepare us for this onslaught of poor life skills.

 

[675015]

And residency doesn't prepare us for this onslaught of poor life skills.

I don't know about that. Half my outpatient panel in residency seems like patients with poor life skills. And I'm not even counting our VA experience.

 

[nexus73]

Vistaril for everyone!

Unless you're an 86 year old lady. Then I'll just keep you on the Valium 5mg tid you've been rx'd for the last 30 years.

 

[NickNaylor]

That kills me. Apparently we now have to medicate for any life stress a patient has

I try and mediate this by setting expectations clearly about what should and should not be expected when I'm seeing a new patient (vs. inheriting an old patient) that is seeking treatment for anxiety. Fortunately in our outpatient clinic we have pretty solid resources for psychotherapy, so I push that as much as possible. But no amount of SSRI is going to help you feel better about the fact that your SSDI of $700/mo is not enough to cover basic living expenses to any significant degree.