Selective serotonin reuptake inhibitor toxicity: Difference between revisions
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[[Category:Toxicology]] | [[Category:Toxicology]] | ||
==Background== | |||
*Selective serotonin reuptake inhibitors (SSRI) 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) | |||
*Overdose is generally benign. Associated with less toxicity than tricyclic antidepressants | |||
*Serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates) | |||
*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''' | |||
**Nausea/vomiting | |||
**Agitation | |||
**Ataxia | |||
**Confusion | |||
*'''Signs''' | |||
**Altered mental status | |||
**Autonomic instability | |||
***Diaphoresis | |||
***Hyperthermia | |||
***Hypertension/hypotension | |||
**Neuromuscular hyperactivity | |||
***Hyperreflexia | |||
***Muscular rigidity | |||
***Resting tremor | |||
==Differential Diagnosis== | |||
*[[Neuroleptic Malignant Syndrome]] | |||
*[[Acetaminophen Toxicity]] | |||
*Withdrawal Syndromes | |||
*[[Encephalitis]] | |||
*[[Heatstroke]] | |||
*[[Hyperthyroidism]] | |||
*[[Meningitis]] | |||
*[[Rhabdomyolysis]] | |||
*[[Tetanus]] | |||
==Evaluation== | |||
===Workup=== | |||
===Diagnosis=== | |||
==Management== | |||
*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 w/ benzodiazepines | |||
*Manage hyperthermia | |||
*If suspecting [[Serotonin Syndrome]], stop all serotonergic medication: | |||
**SSRIs | |||
**Anticonvulsants (valproate) | |||
**Antiemetics (ondansetron, metoclopramide) | |||
**Analgesics (fentanyl, tramadol, methadone) | |||
**Antibiotics (linezolid) | |||
==Disposition== | |||
==See Also== | |||
==External Links== | |||
*[https://litfl.com/ssri-toxicity/ Life in the Fast Lane (LITFL) - SSRI Toxicity] | |||
==References== | |||
<references/> | |||
Revision as of 20:00, 6 July 2022
Background
- Most serious adverse effect is potential to produce Serotonin Syndrome
- Fatalities are uncommon with pure overdoses
Clinical Features
- Nausea and vomiting
- Sedation
- Tremor
- Sinus tachycardia
- QRS, QT prolongation (citalopram only)
- Serotonin syndrome
- Coma and seizures (rare)
Differential Diagnosis
Anticholinergic toxicity Causes
- Medications[1]
- Atropine
- Antihistamines
- Antidepressants
- Antipsychotics
- Muscle relaxants
- Anti-Parkinsonians
- Plants
- Jimson weed (Devil's trumpet)
- Amanita mushroom
Management
- Supportive care
- No role for activated charcoal or gastric lavage
- Magnesium sulfate 2g IV if QTc > 500 msec
- IV benzodiazepines if agitation or seizures
Disposition
- Consider admission for patients who are tachycardic or lethargic 6hr after ingestion
- ECG before clearing a patient with citalopram ingestion
See Also
References
- ↑ Dawson AH, Buckley NA. Pharmacological management of anticholinergic delirium – theory, evidence and practice. Br J Clin Pharmacol. 2015;81(3):516-24.
Background
- Selective serotonin reuptake inhibitors (SSRI) 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)
- Overdose is generally benign. Associated with less toxicity than tricyclic antidepressants
- Serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates)
- 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
- Nausea/vomiting
- Agitation
- Ataxia
- Confusion
- Signs
- Altered mental status
- Autonomic instability
- Diaphoresis
- Hyperthermia
- Hypertension/hypotension
- Neuromuscular hyperactivity
- Hyperreflexia
- Muscular rigidity
- Resting tremor
Differential Diagnosis
- Neuroleptic Malignant Syndrome
- Acetaminophen Toxicity
- Withdrawal Syndromes
- Encephalitis
- Heatstroke
- Hyperthyroidism
- Meningitis
- Rhabdomyolysis
- Tetanus
Evaluation
Workup
Diagnosis
Management
- 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 w/ benzodiazepines
- Manage hyperthermia
- If suspecting Serotonin Syndrome, stop all serotonergic medication:
- SSRIs
- Anticonvulsants (valproate)
- Antiemetics (ondansetron, metoclopramide)
- Analgesics (fentanyl, tramadol, methadone)
- Antibiotics (linezolid)
Disposition
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.