Serotonin syndrome Sertraline , dosing

Voirol P, Hodel PF, Zullino D, Baumann P. Serotonin syndrome after small doses of citalopram or sertraline. J Clin Psychopharmacol 2000 20(6) 713-4. 

Treatment with serotonin-potentiating drugs in usual therapeutic doses can sometimes produce the serotonin syndrome. There are also case reports of this reaction with single doses of SSRIs (see also the monograph on Sertraline) (14). 

Serotonin syndrome after a single dose of sertraline 100 mg has been reported in a 16-year-old girl (6). It responded to a single 4 mg dose of the serotonin antagonist cyproheptadine. 

SSRIs NNRTIs - EFAVIRENZ 1. Possible efficacy and adverse effects, including serotonin syndrome, with fluoxetine 2. Possible 1 efficacy with sertraline 1. Uncertain mechanism possibly bioavailability 2. CYP2B6 contributed most to the demethyla-tion of sertraline, with lesser contributions from CYP2C19, CYP2C9, CYP3A4 and CYP2D6 1. Use with caution consider l dose of fluoxetine 2. Watch for therapeutic failure, and advise patients to report persistence or lack of improvement of symptoms of depression. dose of sertraline as required titrate to clinical response... 

PROTEASE INHIBITORS SSRIs t adverse effects of fluoxetine, paroxetine and sertraline when co-administered with ritonavir (with or without lopinavir). Cardiac and neurological events have been reported, including serotonin syndrome Ritonavir is associated with the most significant interaction of the protease inhibitors due to potent inhibition of CYP3A, CYP2D6, CYP2C9 and CYP2C19 isoenzymes Warn patients to watch for t side-effects of SSRIs and consider 1 dose ofSSRI... 

St. John s wort Fiepericum perforatum) Four patients on sertraline and one on nefazodine developed symptoms diagnosed as serotonin syndrome when St. John s wort was taken concomitantly. Another patient on St. John s wort developed severe sedation after taking a single dose of paroxetine. 

A study in 11 healthy subjects found that paroxetine 20 mg daily for 16 days had no effect on the response to a 6-mg dose of subcutaneous sumatriptan, as measured by prolactin levels. The sumatriptan levels remained unaltered, its cardiovascular effects were unchanged and no clinically significant adverse effects occurred. Other studies report that the concurrent use of sumatriptan and SSRIs (fluoxetine 20 to 60 mg daily, fluvoxamine 200 mg daily, paroxetine 20 to 50 mg daily, sertraline 50 to 100 mg daily) was successful and uneventful. No adverse effects have been noted in 148 other patients. However, a case report describes a 65-year-old woman who had been taking paroxetine 20 mg [daily] for a number of years, who developed confusion, strange behaviour, sinus tachycardia, hypertension and hyperthermia shortly after starting sumatriptan. The serotonin syndrome was diagnosed, and she recovered completely on withdrawal of the two drugs. ... 

An 88-year-old woman taking sertraline 50 mg daily (later increased to 100 mg daily), as well as several other medications was given dextropro-poxyphene with paracetamol and tramadol 200 mg daily increased to 400 mg daily for pain relief after a fracture. Ten days after starting tramadol she became confused, with alterations in cognitive function, tremor, problems with co-ordination and muscle weakness. The serotonin syndrome was suspected and therefore sertraline was withdrawn over a period of 2 days, the dose of tramadol was reduced from 400 to 200 mg daily, and the patient recovered over a period of about 2 weeks. ... 

In another report, the serotonin syndrome occurred after the first dose of sertraline 50 mg in a 75-year-old woman who had been taking tramadol 50 mg daily for 3 days. The concentration of serotonin (5-hydroxytryp-tamine) in her CSF was found to be elevated to 38.5 nanograms/mL (normal value less than 10 picograms/mL)."... 

Several patients taking sertraline developed symptoms diagnosed as the serotonin syndrome after also taking St John s wort. Another patient taking St John s wort developed severe sedation aftertaking a single dose of paroxetine. Isolated cases of mania have also been reported when SSRIs were taken with St John s work... 

---