Serotonin syndrome treatment

Gillman, PK (1999) The serotonin syndrome and its treatment. J. Psychopharmacol. 13 100-109. Heal, DJ, Cheetham, SC, Prow, MR, Martin, KF and Buckett, WR (1998) A comparison of the effects on central 5-HT function of sibutramine hydrochloride and other weight-modifying drugs. Brit. J. Pharmacol. 125 301-308. 

Graudins, A., Stearman, A., and Chan, B. (1998) Treatment of the serotonin syndrome with cyproheptadine./ Emerg Med 16 615-619. 

The following side effects apply to the irreversible, nonselective MAOI antidepressants (phenelzine and tranylcypromine). The most common side effects are orthostatic hypotension, headache, insomnia, weight gain, sexual dysfunction, peripheral edema, and afternoon somnolence. Although MAOIs do not have significant affinity for muscarinic receptors, anticholinergic-like side effects are present at the beginning of treatment. Dry mouth is common but not as marked as in TCA therapy. Fortunately, the more serious side effects, such as hypertensive crisis and serotonin syndrome, are not common. 

The major clinical applications of cyproheptadine are in the treatment of the smooth muscle manifestations of carcinoid tumor and in cold-induced urticaria. The usual dosage in adults is 12-16 mg/d in three or four divided doses. It is of some value in serotonin syndrome, but because it is available only in tablet form, cyproheptadine must be crushed and administered by stomach tube in unconscious patients. 

The serotonin syndrome is a well-established complication of SSRI treatment. It is usually associated with high doses of SSRIs or the use of SSRIs in combination with other serotonin-potentiating agents, such as monoamine oxidase inhibitors (SEDA-22, 24). 

Hamilton S, Malone K. Serotonin syndrome during treatment with paroxetine and risperidone. J Clin Psychopharmacol 2000 20(l) 103-5. 

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). 

The serotonin syndrome is a recognized complication of SSRI treatment. Usually it occurs as part of a drug interaction, when the serotonergic effects of SSRIs are augmented by medications that also have serotonin-potentiating properties (SEDA-22, 14) (SEDA-25, 16). Occasionally, however, the serotonin syndrome can occur after SSRI monotherapy. 

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). 

The serotonin syndrome has been reported during treatment with paroxetine and risperidone (32). A case of edema in a patient taking risperidone and paroxetine has also been reported (33). 

The serotonin syndrome occurred in a 60-year-old woman when the addition of trazodone 50 mg/day to nefazodone 500 mg/day caused confusion, restlessness, sweating, and nausea after the third day of treatment (75). The symptoms settled quickly on withdrawal of both antidepressants. 

Lithium augmentation of antidepressants is a well-established treatment for resistant depression and is usually well tolerated with all classes of antidepressants, although there have been a few reports of the serotonin syndrome with SSRIs (581). It is possible that shared adverse effects could be magnified by combining lithium with various antidepressants (for example tremor, weight... 

A 27-year-old married woman developed symptoms of generalized anxiety disorder and was given buspirone 30 mg/day (32). During treatment she felt depressed and decided to take St John s wort. Two months later she started to have nervousness, aggressiveness, hyperactivity, insomnia, blurred vision, and very short periods of confusion and disorientation. The symptoms were consistent with serotonin syndrome. St John s wort was withdrawn and her symptoms resolved after 1 week. 

Blood concentrations of paroxetine were not obtained, but the authors reported that the patient was homozygous for the 10 form of the CYP2D6 allele, which is associated with low CYP2D6 activity in vivo. While this is an interesting observation, it is unlikely by itself to explain the patient s sensitivity to paroxetine, because this genotjrpe is not uncommon in the Japanese population, and if a lot of Japanese have this genotype, the serotonin syndrome with SSRI monotherapy would be quite common, given the widespread prescription of SSRIs. However, it reinforces clinical advice that in patients new to SSRI treatment it is advisable to start therapy with half the standard dose. 

The serotonin syndrome is a well-established complication of SSRI treatment. It is usually associated with high... 

No prospective studies have been performed to evaluate the treatment of serotonin syndrome, and... 

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