A review of the clinical presentation, etiologies, differential diagnosis, and treatment of serotonin syndrome. A part of Strong Medicine's series on Underappreciated Diseases. #MedEd #Toxicology #SSRI
September 18, 2022 is my second birthday. My symptoms lasted for 20 hours, I passed out countless times, I was shaking UNCONTROLLABLE, I had diarrhea, my heart wanted to jump out, but at the same time I couldn't stand on my feet. When I was conscious I prayed to God to forgive my sins if this is the time for me to leave. After everything, they told me in the emergency room that it was a panic attack, countless infusions, because I was in two hospitals. I knew it wasn't because I was passing out all day. I was on anti-depressants and migraine medication, both of which have high doses of serotonin. I thank God for a second chance, and I am afraid of the incompetence of our doctors. 18.09. is the date of my patron saint and I know who saved my life then. Since then, I've been fighting and struggling with panic attacks, but that day was not one of them.
Learned all about serotonin syndrome in medical school but until you see it the first time and have it in the back of your mind, it can be hard to recognize! We recently had a cancer patient who was on citalopram, trazodone, olanzapine, and recently started on duloxetine for neuropathic pain who ended up coming in with altered mental status. Our attending noticed her hyperreflexia which kind of clinched the diagnosis. I don't typically check reflexes all that often so I definitely learned that I should add that to my repertoire. Also regarding the EMR notifications - I totally agree that they can become so burdensome and the default is to ignore them 99% of the time. They really are important though and hopefully the EMR can continue to be improved so they become more useful rather than just bloat. That part where you discussed all the potential medication complications that can occur if we aren't careful . . . it just made me realize how scary it can be with how much potential harm we can do to patients if we aren't careful with even just a simple new medication prescription.
My 21 year old daughter was prescribed 20mg of Citalopram for ongoing bad anxiety. She got serotonin syndrome within 48 hours. Was this too high a dose to start with or just something that will not work for her? Does she possibly have very high natural serotonin levels and then the Citalopram made it worse? She’s losing hope that anything can help with the anxiety now which is affecting her daily life.
I experienced this after taking a cough and cold otc syrup. I was freaking out. It was 7 years ago. Never did again. I was a med student then and read my ass off to come up with Serotonin syndrome, and realized a lot of doctors weren't aware of it.
I was one of the rare cases needing mechanical ventilation. I was on the vent for 9 days and even coded once. My serotonin syndrome went undiagnosed for a couple years until I lost the ability to move, speak and open my eyes. Then I became very rigid and had upper, lower and ocular clonus and lost consciousness.
I had this for five years. My GP gave me Effexor and tramadol, I thought I was going mad, saw many specialists, wasn't until I went to a new chemist who looked me over and told me he wasn't going to sell me these in combination. Went to my gp and she was bvwet flippent. Left me with severe tachycardia and heart failure. Edit note.. thankyou for this post & no unfortunately, progressive heart failure, uncontrolled hypertension, and progressive tachycardia, kidney damage, COPD, acidocis. I am in my early forties and lived a very clean life.
I'm so sorry to hear what you went through, but thank you for bringing this up. On uncommon occasions, serotonin syndrome can persist for a long time before diagnosis if the presentation is *relatively* mild (relative to the more "classic", acutely life-threatening presentations), particularly if autonomic dysfunction (e.g. tachycardia) and anxiety are the predominant symptoms. Patients and their physicians can mistake the symptoms as manifestations of primary psychiatric disease (which ironically was often the reason for prescribing the causative meds in the first place!). I hope you are doing better now.
Thank you very Much Dr Strong. I think the first case came to flame is from combination of Prozac and Meperidine( Pethidine) morphine derivative pain killer. I am not sure wether they are still in used but it was used widely in my time for post operative pain killer. Actually SSRI and Morphine is not a problem? Selective Monoamine oxidase inhibitor are widely use in Parkinson’s. Dextromethorphan with SSRI or other serotonergic drug drug interaction are common but not fatal to make a news. Patient can feel mild agitated or high or headache like. Patient who is on Welbutrin ( Buproion) and Dextromethorphan could double the dose of Dextromethorphan. The mild case of these phenomena happened often but the fatal case is not thank god.
Sir your videos are too brilliant .... love your work, always wait for your next video. how can I get a ppt/pdf of your excellent work? many thanks sir
Someone gave me sertraline, trazodone, and a 5HTP supplement to start all at once. I didn't get the full syndrome but I had a bad couple days. Thanks for covering this topic.
I suspect I might have this, I'm on 80mg Prozac, 4mg Risperidone. I was on valproate for 10 years up until september last year too... I can't sit still, can't sleep, sweating constantly... they put me on 20mg of propranolol 3 times a day it it hardly does anything. I also get bad gastro-intestinal problems. I was diagnosed with OCD and drug induced psychosis for all this...
O dear I was in A&E yesterday lost a lot of weight, breathing bad, sight much worse, uncontrollable limbs tremors,muscle wastage blood in stools,blood pressure up and down, sweats bad,headaches from hell red raw throat pins and needles arm’s legs muscles constantly moving stressed they get worse confusion memory’s not there ,my tablet’s are Sertraline 100mg,Fluvoxamine 50 mg,Allopurinol 100mg,irbesartan 75 mg,Atorvastatin 40mg,Melatonin 4mg at night,Clopidogrel 75mg,they told me to go home it was drug withdrawal I feel like I am slowly dying no strength can’t figure out anything even a measuring tape live in Jersey Channel Islands U.K. I know 4 of the meds above raise Sertraline hell i am desperate.
One thing I wish my doctor or pharmacist could answer is whether I can take my Pantoprazole (PPI) with my Fluvoxamine (Luvox: SSRI). Being that I’m on a lot of medications for an autoimmune disorder I always check for medication interactions on WebMD when I’m put on a new medication. I was recently put on Fluvoxamine for chronic depression and anxiety brought on by acute stress brought on by my ruminating OCD. It had absolutely no interactions with any other medications I’m taking except for the PPI. Apparently Fluvoxamine can mess with the metabolism of Pantoprazole causing it to amplify the dosage received; so in effect, a 40 mg dose can potentially have the same potency as if I’d taken a 120 mg dose. It greatly bothers me that no one can answer this question as I take the Pantoprazole for chronic GERD and relying on Tums for the past few months to keep my stomach acid in check is just not working. Is there any literature on just how common or uncommon the risk of a severe reaction between Fluvoxamine and Pantoprazole has of occurring? Google seems to have mixed data on this at best and my pharmacist says they don’t see the interaction listed in their system even though I can clearly see it in WebMD’s database. Obviously this is not related to Serotonin Syndrome but can’t hurt to ask.
