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Serotonin syndrome

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Serotonin syndrome
SpecialtyPsychiatry Edit this on Wikidata

Serotonin syndrome, also hyperserotonemia, serotonergic syndrome and sometimes Serotonin Storm, is an illness caused by an excess of serotonin (5-hydroxytryptamine, or 5-HT) in the central nervous system, brought about by the use of prescription or non-prescription drugs, or combinations of these.

Causes

It is most often associated with high doses of serotonergic drugs, when "normal" doses of different serotonergic agents are used in combination, or when different types of antidepressants are changed without an adequate washout period between drugs.

Less frequently it can be caused by moderate dosage of a single serotonergeric drug,[1][2] or in combination with non-serotonergeric drugs such as oxycodone,[3] erythromycin,[4] or St. John's Wort.[5]

Diagnosis

Serotonin syndrome is rare, but it is a serious, potentially life-threatening medical condition. However there is no lab test for the condition, so diagnosis is by symptom observation. It may go unrecognized because it is often mistaken for a viral illness, anxiety, neurological disorder or worsening psychiatric condition.[6] Clinicians must differentiate between serotonin syndrome and neuroleptic malignant syndrome, which has similar symptoms. Patients taking serotonergic drugs and who have sudden onset of the below symptoms should immediately seek medical care.

Signs and symptoms

Symptoms may be classed into three groups:

Insomnia, sleep disruption, and unrefreshing sleep are also reported symptoms, as well as itching and hives.

Drugs which may contribute

Class Drugs
antidepressants MAOIs, TCAs, SSRIs, mirtazapine, venlafaxine, St John's Wort
opioids tramadol, pethidine, oxycodone, morphine...
CNS stimulants phentermine, diethylpropion, amphetamines, sibutramine
5-HT1 agonists triptans
illicit drugs methylenedioxymethamphetamine (MDMA or ecstasy), lysergic acid diethylamide (LSD), cocaine, heroin
others selegiline, tryptophan, buspirone, lithium, linezolid, dextromethorphan (DXM), 5-HTP, chlorpheniramine
Reference: Rossi, 2005[7]; National Prescribing Service, 2005[8]

The combination of MAOIs and other serotonin agonists or precursors poses a particularly severe risk of a life-threatening serotonin syndrome episode. Many MAOIs inhibit monoamine oxidase irreversibly, so that the enzyme cannot function until it has been replaced by the body, which can take at least two weeks. A dangerous serotonin syndrome reaction can occur unless serotonin agonists and even serotonin precursors such as foods containing tryptophan are strictly avoided until the monoamine oxidase has been replaced.

Treatment

There is no antidote to the condition itself, but emergency medical clinicians can administer cyproheptadine or methysergide to control the symptoms.[9] Doing so is important as the symptoms can in severe cases be potentially life threatening.

If the symptoms are not severe or life threatening, optimal treatment consists of discontinuation of the offending medication or medications, offering supportive measures, and waiting for the symptoms to resolve. If the offending medication is discontinued, the condition will often resolve on its own within 24 hours.[10][11]

Neuroleptic malignant syndrome and serotonergic syndrome

The clinical features of neuroleptic malignant syndrome (NMS) and serotonergic syndrome are very similar. This can make differentiating them very difficult.[12]

Features, classically present in NMS, that are useful for differentiating the two syndromes are[13]:

  • Fever
  • Muscle rigidity

References

  1. ^ Gill M, LoVecchio F, Selden B. Serotonin syndrome in a child after a single dose of fluvoxamine. Ann Emerg Med. 1999 Apr;33(4):457-9.
  2. ^ Tomaselli G, Modestin J. Repetition of serotonin syndrome after reexposure to SSRI--a case report. Pharmacopsychiatry. 2004 Sep;37(5):236-8.
  3. ^ Karunatilake H, Buckley NA. Serotonin syndrome induced by fluvoxamine and oxycodone. Ann Pharmacother. 2006 Jan;40(1):155-7. Epub 2005 Dec 20.
  4. ^ Lee DO, Lee CD. Serotonin Syndrome in a Child Associated with Erythromycin. Pharmacotherapy. 1999 Jul;19(7):894-6.
  5. ^ Dannawi M. Possible serotonin syndrome after combination of buspirone and St John's Wort. J Psychopharmacol. 2002 Dec;16(4):401.
  6. ^ Fennell J, Hussain M. Serotonin syndrome:case report and current concepts. Ir Med J. 2005 May;98(5):143-4.
  7. ^ Rossi S, editor. Australian Medicines Handbook 2005. Adelaide: Australian Medicines Handbook; 2005. ISBN 0-9578521-9-3
  8. ^ http://www.nps.org.au/site.php?content=/html/ppr.php&ppr=/resources/Prescribing_Practice_Reviews/ppr32 accessed 16/jul/2006
  9. ^ Sporer KA. The serotonin syndrome: implicated drugs, pathophysiology and management. Drug Saf 1995;13:94–104.
  10. ^ Prator KA. Serotonin syndrome. Journal of Neuroscience Nursing. 2006 Apr;38(2):102-5.
  11. ^ Jaunay E, et al. Serotonin syndrome. Which treatment and when? Nouv Presse Med. 2001 Nov 17;30(34):1695-700
  12. ^ Christensen V, Glenthøj B (2001). "[Malignant neuroleptic syndrome or serotonergic syndrome]". Ugeskr Laeger. 163 (3): 301–2. PMID 11219110.
  13. ^ Birmes P, Coppin D, Schmitt L, Lauque D (2003). "Serotonin syndrome: a brief review". CMAJ. 168 (11): 1439–42. PMID 12771076.{{cite journal}}: CS1 maint: multiple names: authors list (link) Full Free Text.
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