Selective serotonin reuptake inhibitor toxicity: Difference between revisions
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==Background== | ==Background== | ||
*Most serious adverse effect is potential to produce [[serotonin | *Most serious adverse effect is potential to produce [[serotonin syndrome]] | ||
* | **However, serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates) | ||
* | *Pure overdoses are generally benign (mortality uncommon). Associated with less toxicity than tricyclic antidepressants. | ||
*Are the most commonly prescribed antidepressants in the United States<ref>Pirraglia PA, Stafford RS, Singer DE. Trends in Prescribing of Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressant Agents in Adult Primary Care. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):153-157. doi: 10.4088/pcc.v05n0402. PMID: 15213776; PMCID: PMC419384.</ref> | |||
*Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa) | *Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa) | ||
*Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent [[QT prolongation]] and increase risk of [[torsades de pointes]] | |||
*Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent QT prolongation and increase risk of torsades de pointes | |||
==Clinical Features== | ==Clinical Features== | ||
*'''Symptoms''' | *'''Symptoms''' | ||
**Nausea | **[[Nausea and vomiting]] | ||
**Agitation | **[[Agitation]] | ||
**Ataxia | **[[Ataxia]] | ||
**Confusion | **[[Confusion]] | ||
*'''Signs''' | *'''Signs''' | ||
**Altered mental status | **[[Altered mental status]] | ||
**Autonomic instability | **Autonomic instability | ||
***Diaphoresis | ***Diaphoresis | ||
***Hyperthermia | ***[[Hyperthermia]] | ||
***Hypertension/hypotension | ***[[Hypertension]]/[[hypotension]] | ||
***[[Sinus tachycardia]] | |||
**Neuromuscular hyperactivity | **Neuromuscular hyperactivity | ||
***Hyperreflexia | ***Hyperreflexia | ||
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==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
*[[ECG]] | |||
**QRS, [[QT prolongation]] (citalopram only) | |||
===Diagnosis=== | ===Diagnosis=== | ||
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==Management== | ==Management== | ||
*Treatment is mostly supportive. Consult poison control for guidance, if needed. | |||
*Administer [[activated charcoal]] if lethal amount ingested within 1-2 hours | |||
*Continuous cardiac monitoring required for citalopram (>600 mg) and escitalopram (>300mg) for at least 8 hours. | |||
**If citalopram (>1000 mg) and escitalopram (>500 mg) has been ingested then monitor for 12-24 hours | |||
***[[Magnesium]] sulfate 2g IV if QTc > 500 msec | |||
*Manage [[seizures]] with [[benzodiazepines]] | |||
*Manage [[hyperthermia]] | |||
*Treatment is mostly supportive. Consult poison control for guidance | |||
*Administer activated charcoal if lethal amount ingested within 1-2 hours | |||
*Continuous cardiac monitoring required for citalopram (>600 mg) and escitalopram (>300mg) for at least 8 hours. If citalopram (>1000 mg) and escitalopram (>500 mg) has been ingested then monitor for 12-24 hours | |||
*Manage seizures | |||
*Manage hyperthermia | |||
*If suspecting [[Serotonin Syndrome]], stop all serotonergic medication: | *If suspecting [[Serotonin Syndrome]], stop all serotonergic medication: | ||
**SSRIs | **SSRIs | ||
Latest revision as of 21:21, 6 July 2022
Background
- Most serious adverse effect is potential to produce serotonin syndrome
- However, serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates)
- Pure overdoses are generally benign (mortality uncommon). Associated with less toxicity than tricyclic antidepressants.
- Are the most commonly prescribed antidepressants in the United States[1]
- Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa)
- Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent QT prolongation and increase risk of torsades de pointes
Clinical Features
- Symptoms
- Signs
- Altered mental status
- Autonomic instability
- Diaphoresis
- Hyperthermia
- Hypertension/hypotension
- Sinus tachycardia
- Neuromuscular hyperactivity
- Hyperreflexia
- Muscular rigidity
- Resting tremor
Differential Diagnosis
- Serotonin syndrome
- Neuroleptic Malignant Syndrome
- Acetaminophen Toxicity
- Withdrawal Syndromes
- Encephalitis
- Heatstroke
- Hyperthyroidism
- Meningitis
- Rhabdomyolysis
- Tetanus
Anticholinergic toxicity Causes
- Medications[2]
- Atropine
- Antihistamines
- Antidepressants
- Antipsychotics
- Muscle relaxants
- Anti-Parkinsonians
- Plants
- Jimson weed (Devil's trumpet)
- Amanita mushroom
Evaluation
Workup
- ECG
- QRS, QT prolongation (citalopram only)
Diagnosis
Management
- Treatment is mostly supportive. Consult poison control for guidance, if needed.
- Administer activated charcoal if lethal amount ingested within 1-2 hours
- Continuous cardiac monitoring required for citalopram (>600 mg) and escitalopram (>300mg) for at least 8 hours.
- If citalopram (>1000 mg) and escitalopram (>500 mg) has been ingested then monitor for 12-24 hours
- Magnesium sulfate 2g IV if QTc > 500 msec
- If citalopram (>1000 mg) and escitalopram (>500 mg) has been ingested then monitor for 12-24 hours
- Manage seizures with benzodiazepines
- Manage hyperthermia
- If suspecting Serotonin Syndrome, stop all serotonergic medication:
- SSRIs
- Anticonvulsants (valproate)
- Antiemetics (ondansetron, metoclopramide)
- Analgesics (fentanyl, tramadol, methadone)
- Antibiotics (linezolid)
Disposition
- Consider admission for patients who are tachycardic or lethargic 6hr after ingestion
- ECG before clearing a patient with citalopram ingestion
See Also
External Links
References
- ↑ Pirraglia PA, Stafford RS, Singer DE. Trends in Prescribing of Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressant Agents in Adult Primary Care. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):153-157. doi: 10.4088/pcc.v05n0402. PMID: 15213776; PMCID: PMC419384.
- ↑ Dawson AH, Buckley NA. Pharmacological management of anticholinergic delirium – theory, evidence and practice. Br J Clin Pharmacol. 2015;81(3):516-24.