Mild serotonin syndrome

Mild serotonin syndrome occurs in patients who mix St. John s wort (Hypericum perforatum) with serotonin-reuptake inhibitors. 

Trazodone Mild serotonin syndrome A similar case is described with the use of St. 

St. John s wort Mild to moderate depression Gastrointestinal upset, photo-sensitivity. Mild serotonin syndrome with the following medications paroxetine, trazodone, sertraline, and nefazodone. May decrease digoxin levels. May decrease cyclosporine serum concentrations. Combined oral contraceptives—breakthrough bleeding. 

Serotonin reuptake Delirium, mild serotonin syndromes... 

Lethargy/incoherence Mild serotonin syndrome Mild serotonin syndrome Decreased theophylhne concentrations... 

An open 6-week study in 19 patients with major depression taking paroxetine (or fluoxetine) 20 mg daily to which moclobemide up to 600 mg daily was added, indieated that these eombinations were possibly effective. An extension of this study with 50 patients is reported elsewhere. However, a range of adverse effeets oeeurred in some patients, the clearest one being insomnia, and the serotonin syndrome was seen in one patient. Conversely, the serotonin syndrome was not seen in another study, where low initial doses and gradual up-titration of both paroxetine and moclobemide was used. Two possible cases of mild serotonin syndrome... 

Dmg-induced serotonin syndrome is generally mild and resolves when the offending drugs are stopped. However, it can be severe and deaths have occurred. A large number of drugs have been implicated including tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), selective serotonin re-uptake inhibitors (SSRIs), pethidine, lithium, and dextromethorphan. The most severe type of reaction has occurred with the combination of selective serotonin re-uptake inhibitors and monoamine oxidase inhibitors. Both non-selective MAOIs such as phenelzine and selective MAOIs such as moclobemide and selegiline have been implicated. 

Central Serotonin Syndrome is manifest by autonomic, neuromuscular, and cognitive symptoms. Mild symptoms can include tremor, incoordination, and confusion. Moderate symptoms can manifest as shivering, sweating, hyperreflexia, and agitation, and severe symptoms include fever, myoclonus, and diarrhea. This syndrome is usually associated with two or more drugs that increase central serotonin transmission and affect the 5-HTia receptor (see Table 5.4). 

The combination of MAOIs with meperidine, and perhaps with other phenylpiperidine analgesics, also has been implicated in fatal reactions attributed to the serotonin syndrome. Aspirin, nonsteroidal anti-inflammatory drugs, and acetaminophen should be used for mild to moderate pain. Of the narcotic agents, codeine and morphine are safe in combination with MAOIs, although doses may need to be lower than usual. 

A 23-year-old Japanese woman with major depression took a single dose of paroxetine (20 mg) and 1 hour later had agitation, myoclonus, mild hyperthermia (37.5°C), sweating, and diarrhea, symptoms that meet the criteria for the serotonin syndrome she recovered with supportive treatment over 3 days (2). 

In a study in 14 healthy subjects, two 20-mg doses of dextromethorphan given 4 hours apart, before and during the use of linezolid 600 mg every 12 hours, had no effect on linezolid pharmacokinetics. The AUC and maximum level of the dextromethorphan metabolite, dextrorphan was decreased by 30%, but this was not considered sufficient to warrant any dosing alterations. There was no evidence of the serotonin syndrome, as measured by changes in body temperature, alertness and mental performance. However, the manufacturers describe one case where the concurrent use of linezolid and dextromethorphan resulted in the serotonin syndrome. Linezolid has mild reversible MAOI activity, and the serotonin syndrome has been described when dextromethorphan was taken by patients also taking antidepressant MAOIs, see MAOIs or RIMAs + Dextromethorphan , p.l 134. If the concurrent use of linezolid and dextromethorphan is considered necessary, it would seem prudent to monitor for symptoms of the serotonin syndrome , (p.9). 

A depressed man taking clomipramine 175 mg, levomepromazine 25 mg and flunitrazepam 2 mg daily, was started on lithium 600 mg daily. About one week later, after his dosage of lithium was raised to 1 g daily and he developed the serotonin syndrome (myoclonus, shivering, tremors, incoordination). Due to this reaction, and because his serum-lithium levels were 1.6 mmol/L, the lithium was stopped. The serotonin syndrome then abated. The clomipramine dosage was reduced, but some mild symptoms remained until the clomipramine was stopped. He responded well to lithium 600 mg daily alone, without developing the serotonin syndrome. ... 

In contrast, one woman was switched directly from phenelzine 60 mg daily to tranylcypromine 20 mg daily without any obvious problems (blood pressure was on the high side, but within the usual range for this patient). She was abruptly switched directly back to phenelzine, again without any adverse effect. " Similarly, a review of 8 cases of patients who were switched rapidly from tranylcypromine to phenelzine (3 cases) or vice versa (5 cases) found that 7 patients tolerated the switch well with minimal or no adverse effects. However the eighth patient experienced anxiety, nausea, hyperventilation, flushing, sense of doom, and increased insomnia, which may have been a mild form of the serotonin syndrome. ... 

These seem to be, so far, the only reports of the serotonin syndrome being attributed to an interaetion between an SSRI and dextromethorphan. However, it has been suggested that the ineidenee of mild serotonin excess (as seen in with citalopram) may be more eommon than is known. The general importance of this apparent interaetion is therefore very uncertain. The SSRIs are now very widely prescribed and dextromethorphan is a rel-... 

Neuroleptic Malignant Syndrome (NMS) is a life-threatening syndrome associated with dopamine antagonism Serotonin Syndrome (SS) looks similar, but results from excessive serotonin. Both can kill, and mild presentations can precede full-blown syndromes. Think NMS or SS with any combination of HARD symptoms ... 

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