Selective serotonin reuptake inhibitor toxicity: Difference between revisions
m (Rossdonaldson1 moved page SSRI toxicity to Selective serotonin reuptake inhibitor toxicity) |
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==Background== | ==Background== | ||
*Most serious adverse effect is potential to produce [[ | *Most serious adverse effect is potential to produce [[serotonin Syndrome]] | ||
*Fatalities are uncommon with pure overdoses | *Fatalities are uncommon with pure overdoses | ||
*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== | ==Clinical Features== | ||
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*[[Coma]] and [[seizures]] (rare) | *[[Coma]] and [[seizures]] (rare) | ||
==Clinical Features== | ==Clinical Features== | ||
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***Muscular rigidity | ***Muscular rigidity | ||
***Resting tremor | ***Resting tremor | ||
==Differential Diagnosis== | |||
*[[Serotonin syndrome]] | |||
{{Anticholinergic types}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*[[Rhabdomyolysis]] | *[[Rhabdomyolysis]] | ||
*[[Tetanus]] | *[[Tetanus]] | ||
==Evaluation== | ==Evaluation== | ||
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===Diagnosis=== | ===Diagnosis=== | ||
==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 | |||
==Management== | ==Management== | ||
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**Analgesics (fentanyl, tramadol, methadone) | **Analgesics (fentanyl, tramadol, methadone) | ||
**Antibiotics (linezolid) | **Antibiotics (linezolid) | ||
==Disposition== | ==Disposition== | ||
*Consider admission for patients who are tachycardic or lethargic 6hr after ingestion | |||
*ECG before clearing a patient with citalopram ingestion | |||
==See Also== | ==See Also== | ||
*[[Serotonin syndrome]] | |||
*[[SNRI Toxicity]] | |||
==External Links== | ==External Links== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Toxicology]] |
Revision as of 20:04, 6 July 2022
Background
- Most serious adverse effect is potential to produce serotonin Syndrome
- Fatalities are uncommon with pure overdoses
- 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
- Nausea and vomiting
- Sedation
- Tremor
- Sinus tachycardia
- QRS, QT prolongation (citalopram only)
- Serotonin syndrome
- Coma and seizures (rare)
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
Anticholinergic toxicity Causes
- Medications[2]
- Atropine
- Antihistamines
- Antidepressants
- Antipsychotics
- Muscle relaxants
- Anti-Parkinsonians
- Plants
- Jimson weed (Devil's trumpet)
- Amanita mushroom
Differential Diagnosis
- Neuroleptic Malignant Syndrome
- Acetaminophen Toxicity
- Withdrawal Syndromes
- Encephalitis
- Heatstroke
- Hyperthyroidism
- Meningitis
- Rhabdomyolysis
- Tetanus
Evaluation
Workup
Diagnosis
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
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
- 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.