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Serotonin Syndrome/Serotonin Toxicity Cynthia Wright Talton, DNP, FNP-BC

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Serotonin Syndrome/Serotonin Toxicity Cynthia Wright Talton, DNP, FNP-BC CLINICAL REVIEW Serotonin Syndrome/Serotonin Toxicity Cynthia Wright Talton, DNP, FNP-BC Objective: This review of serotonin syndrome or serotonin combinations of commonly prescribed medications used to toxicity covers the years 2014 to 2019, including information treat both veteran and nonveteran patients and includes the on pathophysiology, etiology, and diagnosis, 3 criteria for latest information on offending medications. diagnosing serotonin syndrome, and criteria for neuroleptic Conclusions: Prevention of serotonin toxicity includes malignant syndrome. informed clinicians, patient education, careful prescribing Importance: The review highlights the potential lethal and monitoring, and avoidance of multidrug regimens. Cynthia Talton is a Nurse erotonin, or 5-hydroxytryptamine This paper reviews the potential lethal Practitioner in the Outpatient (5-HT), is a chemical neurotransmit- combinations of commonly prescribed Mental Health Clinic at the ter in the central and peripheral ner- medications used to treat both veteran and Veterans Affairs Medical S 1 Center in Salem, Virginia. vous systems that was discovered in 1940s. nonveteran patients and includes the lat- Correspondence: One of the most widely studied chemical est information on offending medications; Cynthia Talton ([email protected]) messengers, serotonin influences many a presentation of symptoms from in utero physiologic functions in humans, including to adult; diagnostic criteria; and recom- Fed Pract. 2020;37(10):452-459 regulation of mood, sleep-wake cycle, ap- mended treatments. doi:10.12788/fp.0042 petite suppression, memory, emesis, breath- The Veterans Health Administration ing, cognition, blood coagulation, libido, (VHA) and non-VHA health care providers and many other functions.2 In 1992, Insel can play a key role in identifying and pre- and colleagues first documented the toxic venting serotonin syndrome/ST by keeping symptoms produced from too much sero- abreast of the latest updates of potentially tonin in the central and peripheral nervous lethal drug combinations. Commonly pre- systems, naming it serotonin syndrome.3,4 scribed medications with the potential for a reaction include antidepressants, anxiolytics, SEROTONIN SYNDROME pain medications, antinausea medications, Experts in the fields of psychiatry, pharmacy, herbal medications, and over-the-counter and toxicology refer to these symptoms as (OTC) medications, such as cough suppres- serotonin toxicity, because the symptoms sants. Patients may be at increased risk for ST result from the toxic effects of too much sero- due to the growth of polypharmacy manage- tonin.5-9 The term toxicity instead of syndrome ment of comorbidities. “clarifies that it is a form of poisoning, just as lithium toxicity is a form of poisoning.”6 Antidepressants Therefore, serotonin toxicity (ST) can de- Over the past decade, antidepressant use velop with administration of any serotonin- has increased substantially in the US, enhancing medication, including therapeutic United Kingdom, and Canada.14 Also the use, polypharmacy, or accidental/intentional types of antidepressants prescribed has drug overdose. changed and been replaced with the newer The incidence of ST has increased over agents. The selective serotonin reuptake the past decade.5,6,10,11 Several reasons ex- inhibitors (SSRIs) and selective norepi- plain this increase: (1) ST mirrors the nephrine reuptake inhibitors (SNRIs) have increase in depression in the US popula- replaced the older tricyclics (TCAs) and tions10,12,13; (2) There has been an increase monoamine oxidase inhibitors (MAOIs) in off-label antidepressant prescribing by as first-line treatments for depression due both primary care and mental health pro- to their improved comparative efficacy, re- viders14-16; (3) the increased use of illicit duced mortality following overdose, ad- drugs13; (4) an increase in suicide attempts verse effects (AEs) that are more tolerable with antidepressants17; and (5) increased for most patients, and the SSRIs have no use of opioids for pain management, in- anticholinergic properties (except parox- cluding both prescription and illicit use.11,14 etine) (Table 1).18 452 • FEDERAL PRACTITIONER • OCTOBER 2020 mdedge.com/fedprac TABLE 1 Serotonin-Elevating Medications SRIs SGA Opioids Illicit Drugs OTC/Herbals Disputeda SSRIs Ziprasidone Meperidine MDMA/Ecstasy St. John’s Wort Antidepressants (es)citalopram Amitriptyline Fluoxetine Methadone Cocaine L-tryptophan Mirtazepine Fluvoxamine Trazodone Paroxetine Pentazocine Amphetamines Ginseng Nefazodone Sertraline Bupropion Vilazodone Pethidine Methamphetamine Dextromethorphan Vortioxetine Tramadol Phentermine S-adenosyl-L-methionine Antiemetics SNRIs (SAMe) Ondansetron (des)venlafaxine LSD (lysergic acid Metoclopramide Duloxetine diethylamide) Chlorpheniramine (levo)milnacipran Tryptans Bath salts Brompheniramine TCAs Buspirone Clomipramine Imipramine Olanzapine MAOIs Lithium Moclobemide Isocarboxazid Fentanyl Phenelzine Tranylcypromine Methylphenidate Methylene blue Linezolid (weak) Cyclobenzaprine Isoniazid (weak) Metaxolone (weak) Abbreviations: LSD, lysergic acid diethylamide; MAOIs, monoamine oxidase inhibitors; MDMA, methylenedioxymethamphetamine; OTC, over-the-counter; SGA, second-generation antipsychotics; SNRIs, selective norepinephrine reuptake inhibitors; SRI, serotonin reuptake inhibitor; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants. aDisputed-experts disagree on these medications causing serotonin syndrome/toxicity because of their mechanisms of action. In 2017 the National Institute of Mental patient visits in a western portion of the Health reported that about 17 million adults US found 12.9% of the prescriptions filled and 3 million adolescents (aged 11-18 years) were off-label.15 In Minnesota, off-label pre- experienced at least 1 episode of major de- scribing of antidepressants was found to pression.19 About 40% of US veterans will ex- contribute to an increase in drug interac- perience depression, which is 3 times higher tions in elderly nursing home residents.24 than the rate of the general US population.12 An investigation by the Military Times A random sampling survey conducted of of the military community revealed off- about 17,000 active-duty service members by label prescribing occurs not only with an- the US Department of Defense (DoD) from tidepressant medications, but also with an- November 2015 to April 2016 revealed 9.4% ticonvulsants, antipsychotics, anti-anxiety reported depression.20 Antidepressant usage drugs, and antiepileptic medications.14 in the US and among veterans continues to A case report that brought ST to the fore- increase.12,16 In 2018, the list of top US pre- front occurred in the 1980s and involved a scribed drugs, included sertraline (14th), college student.25 She was initially diagnosed citalopram (21st), trazodone (24th), and es- with the flu. Her symptoms progressed over a citalopram (26th).21 Antidepressant prescrib- 24-hour period despite treatment, leading to ing in the US increased 18% from 2012 to seizures, hyperthermia, generalized clonus, 2017.22 This trend also continues within the muscle rigidity, respiratory failure, and death military with a 40% increase of antidepres- because of unrecognized ST. Her combina- sant use in the past decade.16 tion of serotonin-elevating drugs included One reason for the increase in antide- meperidine, phenelzine, chlorpheniramine, pressant use is off-label prescribing.14,23 A and haldol. On autopsy, there were traces of sampling of about 2 billion psychiatric out- cocaine found in some of her tissue samples. mdedge.com/fedprac OCTOBER 2020 • FEDERAL PRACTITIONER • 453 Serotonin Toxicity TABLE 2 Drugs Causing Moderate to Severe ST Symtoms4 depression with SSRIs, SNRIs, TCAs, and MAOIs.29 Three of the most studied receptors Drug Classes Drug Combinations include 5-HTIA,5-HT1B, and 5-HT2A. MAOIs MAOIs + SSRIs or SNRIs or TCAs or opiates Etiology Imipramine + tranylcypromine Phenelzine + meperidine Most serotonin-induced drug fatalities occur Methylene blue + clomipramine or paroxetine when combining serotonergic drugs that work through different pathways (Table 2).30 SSRIs SSRIs + MAOIs or TCAs or SNRIs or opiates or tryptans The most toxic combination of serotonin- Fluoxetine + carbamazepine or phentermine or fentanyl enhancing drugs includes MAOIs taken SNRIs SNRIs + TCAs or MAOIs or opiates or triptans with SSRIs or SNRIs, or a combination of Fluoxetine + mirtazapine or phentermine or fentanyl 2 MAOIs.5-9 Other potentially lethal combinations may Other antidepressants Mirtazapine + SSRIs Trazodone + amitriptyline + lithium include polypharmacy with antidepressants, pain medications, OTC medications, and il- Opiates Opiates + MAOIs or SSRIs or SNRIs or triptans licit drugs. Linezolid, a new synthetic anti- microbial, is considered to be a weak MAOI. Cold remedies Dextromethorphan + SSRIs or TCAs or atypical Therefore, prescribing it with other sero- antipsychotics tonin-elevating agents has been reported to 18 Atypical antipsychotics Olanzapine + citalopram and lithium precipitate ST. Risperidone + paroxetine or fluoxetine Most cases of ST do not require hospital- ization and can be managed by stopping the Antibiotics/antifungals Linezolid + SSRIs or tapentadol medication or decreasing the dose. Thera- Fluconazole + citalopram Ciprofloxacin + methadone + venlafaxine peutic doses of a single drug are highly un- likely to cause toxicity, although there have Abbreviations: MAOIs, monoamine
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